DRAFT PREVIEW DSRIP Category C Measure Specifications · 2017-06-27 · Patients who received a...

DRAFT Category C Measure Specifications 06/22/2017 1

DRAFT PREVIEW DSRIP Category C

Measure Specifications Measure Set Page #

Bundle A1: Improved Chronic Disease Management: Diabetes Care .......................................................... 2

Bundle A2: Improved Chronic Disease Management: Heart Disease ......................................................... 13

Bundle B1: Care Transitions & Hospital Readmissions ............................................................................... 24

Bundle B2: Patient Navigation & ED Diversion ........................................................................................... 33

Bundle C1: Primary Care Prevention - Healthy Texans ............................................................................... 42

Bundle C2: Primary Care Prevention - Cancer Screening & Follow-Up ...................................................... 52

Bundle C3: Hepatitis C................................................................................................................................. 61

Bundle D1: Pediatric Primary Care .............................................................................................................. 69

Bundle D3: Pediatric Hospital Safety .......................................................................................................... 78

Bundle D4: Pediatric Chronic Disease Management: Asthma .................................................................... 83

Bundle E1: Improved Maternal Care .......................................................................................................... 91

Bundle F1: Improved Access to Adult Dental Care ................................................................................... 103

Bundle F2: Preventive Pediatric Dental .................................................................................................... 106

Bundle G1: Palliative Care ......................................................................................................................... 110

Bundle H1: Integration of Behavioral Health in a Primary Care Setting ................................................... 118

Bundle H2: Behavioral Health and Appropriate Utilization ...................................................................... 124

Bundle H3: Chronic Non-Malignant Pain Management ........................................................................... 134

Bundle H4: Integrated Care for People with Serious Mental Illness ........................................................ 141

Bundle I1: Specialty Care .......................................................................................................................... 144

Bundle J1: Hospital Safety ......................................................................................................................... 146

Bundle K1: Rural Preventive Care ............................................................................................................. 155

Bundle K2: Rural Emergency Care ............................................................................................................ 169

L1: Local Health Department Measures ................................................................................................... 177

M1: Community Mental Health Center Measures ................................................................................... 214

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BUNDLE A1: IMPROVED CHRONIC DISEASE MANAGEMENT: DIABETES CARE

A1-111: Comprehensive Diabetes Care: Eye Exam (retinal) performed Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam

(retinal) performed.

DY7/DY8 Program ID 111

NQF Number 0055

Measure Steward NCQA

Link to Measure Citation http://www.qualityforum.org/QPS/0055

Measure Parts 1

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: 0.6807 MPL: 0.4453

Numerator Description Patients who received an eye screening for diabetic retinal disease. This includes people with diabetes who had the following: -A retinal or dilated eye exam by an eye care professional (optometrists or ophthalmologist) in the measurement year OR -A negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. For exams performed in the year prior to the measurement year, a result must be available.

Denominator Description Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

Inclusions None listed by measure steward.

Exclusions Exclude patients who did not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes in any setting, during the measurement year or the year prior to the measurement year.

DSRIP Specified Setting Primary Care, Outpatient Specialty Care

Data Source Claims (Only), Electronic Health Record (Only), Paper Records, Pharmacy

Measure Point Value 1

Additional Notes

CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; MACRA MIPS

Measure.

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http://www.qualityforum.org/QPS/0055


A1-112: Comprehensive Diabetes Care: Foot Exam Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot

exam (visual inspection and sensory exam with mono filament and a pulse exam) during the

measurement year.


NQF Number 0056



Measure Parts 1

Benchmark Description NA HPL: NA MPL: NA

Numerator Description Patients who received a foot exam (visual inspection and sensory exam with monofilament and pulse exam) during the measurement year.







Additional Notes


Measure.

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A1-113: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received an HbA1c

test during the measurement year.


NQF Number 0057



Measure Parts 1


Numerator Description Patients who had an HbA1c test performed during the measurement year.



Exclusions Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients who did not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes in any setting, during the measurement year or the year prior to the measurement year.


Data Source Claims (Only), Electronic Health Record (Only), Laboratory, Paper Records, Pharmacy


Additional Notes

CMS Alignment: Adult Core Set; CMS Consensus Core Set: ACO and PCMH / Primary Care Measures;

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A1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent

HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result,

or if an HbA1c test was not done during the measurement year.


NQF Number 0059



Measure Parts 1


Numerator Description Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out of range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure.


Inclusions Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients who did not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes in any setting, during the measurement year or the year prior to the measurement year.





Additional Notes

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MACRA MIPS Measure.

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A1-116: Comprehensive Diabetes Care: Medical Attention for Nephropathy Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a

nephropathy screening or monitoring test or had evidence of nephropathy during the measurement

year.


NQF Number 0062



Measure Parts 1


Numerator Description Patients who received a nephropathy screening or monitoring test or had evidence of nephropathy during the measurement year.







Additional Notes


Measure.

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A1-207: Diabetes care: BP control (<140/90mm Hg) Measure Description:


blood pressure level taken during the measurement year is <140/90 mm Hg.


NQF Number 0061



Measure Parts 1


Numerator Description Patients whose most recent blood pressure level was <140/90 mm Hg during the measurement year. The outcome being measured is a blood pressure reading of <140/90 mm Hg, which indicates adequately controlled blood pressure. Adequately controlled blood pressure in patients with diabetes reduces cardiovascular risks and microvascular diabetic complications.

Denominator Description Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 and type 2) during the measurement year or the year prior to the measurement year. See question S.7 Denominator Details for methods to identify patients with diabetes.


Exclusions Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients who did NOT have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year. AND either: -A diagnosis of polycystic ovaries, in any setting, any time in the patient’s history through December 31 of the measurement year, or -A diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.


Data Source Claims (Only), Electronic Health Record (Only), Laboratory, Other, Paper Records, Pharmacy


Additional Notes

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A1-208: Comprehensive Diabetes Care LDL-C Screening Measure Description:

The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who received an LDL-C



NQF Number 0063



Measure Parts 1


Numerator Description Members who had an LDL-C test performed during the measurement year.

Denominator Description Members 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.


Exclusions Exclude members with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur at any time in the member’s history, but must have occurred by the end of the measurement year. Exclude members with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur during the measurement year or the year prior to the measurement year, but must have occurred by the end of the measurement year. Risk Adjustment:


Data Source Claims (Only)


Additional Notes

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A1-247: Reduce Emergency Department visits for Diabetes Measure Description:

Rate of ED utilization for preventable Diabetes conditions or complications


NQF Number NA

Measure Steward None

Link to Measure Citation https://hhs.texas.gov/sites/hhs/files/documents/laws-regulations/policies-rules/1115-docs/DY5/Category-3-Outcomes-Compendium.pdf

Measure Parts 1


Numerator Description Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period

Denominator Description Total number of ED visits for individuals 18 years or older during the measurement period

Inclusions Preventable diabetes conditions as those associated with the Diabetes ACSC diagnostic codes: 250.0, 250.1, 250.2, 250.3, 250.8, 250.9 (http://www.mdch.state.mi.us/CHI/HOSP/ICD9CM1.HTM)

Exclusions Exclude diabetes with renal manifestations [250.4], diabetes with ophthalmic manifestations [250.5], diabetes with neurological manifestations [250.6] and diabetes with peripheral circulatory disorders [250.7]

DSRIP Specified Setting ED

Data Source Administrative Claims, Electronic Health Record, Clinical Data, Registration data


Additional Notes

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https://hhs.texas.gov/sites/hhs/files/documents/laws-regulations/policies-rules/1115-docs/DY5/Category-3-Outcomes-Compendium.pdf




A1-321: Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation (eMeasure) Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a

neurological examination of their lower extremities within 12 months


NQF Number 0417

Measure Steward American Podiatric Medical Association


Measure Parts 1


Numerator Description Patients who had a lower extremity neurological exam performed at least once within 12 months Definition: Lower Extremity Neurological Exam – Consists of a documented evaluation of motor and sensory abilities and should include: 10-g monofilament plus testing any one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold), however the clinician should perform all necessary tests to make the proper evaluation. Numerator Quality-Data Coding Options for Reporting Satisfactorily: Lower Extremity Neurological Exam Performed G8404: Lower extremity neurological exam performed and documented OR Lower Extremity Neurological Exam not Performed for Documented Reasons G8406: Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure OR Lower Extremity Neurological Exam not Performed G8405: Lower extremity neurological exam not performed

Denominator Description All patients aged 18 years and older with a diagnosis of diabetes mellitus


Exclusions Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure, for example patient bilateral amputee, patient has condition that would not allow them to accurately respond to a neurological exam (dementia, Alzheimer´s, etc.), patient has previously documented diabetic peripheral neuropathy with loss of protective sensation.


Data Source Claims (Only), Other, Paper Records


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Additional Notes

MACRA MIPS Measure.

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BUNDLE A2: IMPROVED CHRONIC DISEASE MANAGEMENT: HEART DISEASE

A2-103: Controlling High Blood Pressure Measure Description:

The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose

blood pressure (BP) was adequately controlled (<140/90) during the measurement year.


NQF Number 0018



Measure Parts 1


Numerator Description The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.

Denominator Description Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.


Exclusions Exclude all patients with evidence of end-stage renal disease (ESRD) on or prior to the end of the measurement year. Documentation in the medical record must include a related note indicating evidence of ESRD. Documentation of dialysis or renal transplant also meets the criteria for evidence of ESRD. Exclude all patients with a diagnosis of pregnancy during the measurement year. Exclude all patients who had an admission to a nonacute inpatient setting during the measurement year.


Data Source Claims (Only), Electronic Health Record (Only), Paper Records


Additional Notes BAT Recommendation to allow follow-up home blood pressure readings recorded in E H R/medical record

CMS Alignment: Adult Core Set; CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; CMS

Consensus Core Set: Cardiovascular Measures; MACRA MIPS Measure.

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A2-104: Medical Assistance with Smoking and Tobacco Use Cessation (MSC) - Modified Denominator Measure Description:

Assesses different facets of providing medical assistance with smoking and tobacco use cessation:

Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18

years of age and older who were current smokers or tobacco users and who received advice to quit

during the measurement year.

Discussing Cessation Medications: A rolling average represents the percentage of patients 18 years of

age and older who were current smokers or tobacco users and who discussed or were recommended

cessation medications during the measurement year.

Discussing Cessation Strategies: A rolling average represents the percentage of patients 18 years of age

and older who were current smokers or tobacco users and who discussed or were provided cessation

methods or strategies during the measurement year.


NQF Number 0027 (Modified)



Measure Parts 3

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: Advising Smokers to Quit: 0.8185 Discussing Cessation Medications: 0.5839 Discussing Cessation Strategies: 0.5175 MPL: Advising Smokers to Quit: 0.7314 Discussing Cessation Medications: 0.4301 Discussing Cessation Strategies: 0.3886

Numerator Description Component 1: Advising Smokers and Tobacco Users to Quit (ASTQ) Patients who received advice to quit smoking or using tobacco from their doctor or health provider Component 2: Discussing Cessation Medications (DSCM) Patients who discussed or received recommendations on smoking or tobacco cessation medications from their doctor or health provider Component 3: Discussing Cessation Strategies (DSCS) Patients who discussed or received recommendations on smoking or tobacco cessation methods and strategies other than medication from their doctor or health provider

Denominator Description Patients 18 years and older who indicated that they were current smokers or tobacco users during the measurement year.


Exclusions None listed by measure steward.


Data Source Patient Reported Data


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Additional Notes

CMS Alignment: Adult Core Set;

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A2-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Measure Description:

Percentage of patients aged 18 years and older with a documented BMI during the encounter or during

the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is

documented during the encounter or during the previous six months of the encounter

Normal Parameters:

Age 65 years and older BMI >= 23 and < 30

Age 18 – 64 years BMI >= 18.5 and < 25


NQF Number 0421 / 2828 eMeasure

Measure Steward CMS

Link to Measure Citation http://www.qualityforum.org/QPS/0421 http://www.qualityforum.org/QPS/2828

Measure Parts 1


Numerator Description Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.

Denominator Description There are two (2) Initial Patient Populations for this measure: Initial Patient Population 1: All patients 18 through 64 years on the date of the encounter with at least one eligible encounter during the measurement period. Initial Patient Population 2: All patients 65 years of age and older on the date of the encounter with at least one eligible encounter during the measurement period.


Exclusions Initial Patient Population 1: Patients who are pregnant or encounters where the patient is receiving palliative care, refuses measurement of height and/or weight, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient´s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate. Initial Patient Population 2: Encounters where the patient is receiving palliative care, refuses measurement of height and/or weight, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient´s health status, or there is any other reason documented in the medical

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record by the provider explaining why BMI measurement was not appropriate.


Data Source Other


Additional Notes


Measure; CCBHC Measure.

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A2-206: Cholesterol management for patients with cardiovascular conditions Measure Description:

Percentage of patients 18 to 75 years of age who were discharged alive for acute myocardial infarction

(AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) in the year

prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the

measurement year and the year prior to the measurement year, who had each of the following during

the measurement year: • Low-density lipoprotein cholesterol (LDL-C) screening performed • LDL-C

control (less than 100 mg/dL)


NQF Number NA


Link to Measure Citation https://www.qualitymeasures.ahrq.gov/summaries/summary/47175

Measure Parts 1


Numerator Description Percentage of patients 18 to 75 years of age who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) in the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year, who had each of the following during the measurement year: • Low-density lipoprotein cholesterol (LDL-C) screening performed • LDL-C control (less than 100 mg/dL)

Denominator Description Patients age 18 to 75 years as of the last day of the measurement year who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) in the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year




Data Source TBD


Additional Notes

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https://www.qualitymeasures.ahrq.gov/summaries/summary/47175


A2-208: Comprehensive Diabetes Care LDL-C Screening Measure Description:




NQF Number 0063



Measure Parts 1









Additional Notes

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A2-210: PQRS #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Measure Description:

Percentage of patients aged 18 years and older seen during the reporting period who were screened for

high blood pressure AND a recommended follow-up plan is documented based on the current blood

pressure (BP) reading as indicated


NQF Number NA

Measure Steward CMS

Link to Measure Citation https://pqrs.cms.gov/dataset/2016-PQRS-Measure-317-11-17-2015/bqda-3reh

Measure Parts 1


Numerator Description Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive NUMERATOR NOTE: Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, BP screening and follow-up must be performed once per measurement period. For patients with Normal blood pressure a follow-up plan is not required.

Denominator Description All patients aged 18 years and older

Inclusions Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years AND Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90880, 92002, 92004, 92012, 92014, 96118, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99281, 99282, 99283, 99284, 99285, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, D7140, D7210, G0101, G0402, G0438, G0439



Data Source TBD


Additional Notes

MACRA MIPS Measure.

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https://pqrs.cms.gov/dataset/2016-PQRS-Measure-317-11-17-2015/bqda-3reh



A2-246: Reduce Emergency Department visits for Selected Condition or Conditions: CHF, Diabetes, Angina/Hypertension, Behavioral Health & Substance Abuse, COPD, or Dental Measure Description:

Rate of ED utilization for selected preventable conditions or complications. Providers will select one or

more targeted conditions from the approved list.


NQF Number NA



Measure Parts 1


Numerator Description Rate of ED utilization for selected preventable conditions or complications. Providers will select one or more targeted conditions from the approved list.

Denominator Description Total number of ED Visits with a primary or secondary diagnosis of selected condition for any individual 18 years and older during the measurement period

Inclusions Various

Exclusions Various




Additional Notes

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A2-384: Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following chronic obstructive pulmonary disease (COPD) hospitalization Measure Description:

The measure estimates a hospital-level 30-day, all-cause, risk-standardized readmission rate (RSRR) for

patients discharged from the hospital with either a principal discharge diagnosis of COPD or a principal

discharge diagnosis of respiratory failure with a secondary diagnosis of acute exacerbation of COPD. The

outcome (readmission) is defined as unplanned readmission for any cause within 30 days of the

discharge date for the index admission (the admission included in the measure cohort). A specified set

of planned readmissions do not count in the readmission outcome. CMS annually reports the measure

for patients who are 65 years or older, are enrolled in fee-for-service (FFS) Medicare, and hospitalized in

non-federal hospitals.


NQF Number 1891

Measure Steward CMS


Measure Parts 1


Numerator Description The outcome for this measure is 30-day readmission. We define readmission as an inpatient admission for any cause, with the exception of certain planned readmissions, within 30 days from the date of discharge from the index admission for patients discharged from the hospital with a principal discharge diagnosis of COPD or principal discharge diagnosis of respiratory failure with a secondary discharge diagnosis of acute exacerbation of COPD. If a patient has more than one unplanned admission (for any reason) within 30 days after discharge from the index admission, only the first one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each admitted patient has an unplanned readmission within 30 days. However, if the first readmission after discharge is considered planned, any subsequent unplanned readmission is not counted as an outcome for that index admission because the unplanned readmission could be related to care provided during the intervening planned readmission rather than during the index admission.

Denominator Description This claims-based measure can be used in either of two patient cohorts: (1) patients aged 65 years or older or (2) patients aged 40 years or older. We have explicitly tested the measure in both age groups. The cohort includes admissions for patients discharged from the hospital with either a principal discharge diagnosis of COPD (see codes below) OR a principal discharge diagnosis of respiratory failure (see codes below) with a secondary discharge diagnosis of acute exacerbation of COPD (see codes below) and with a complete claims history for the 12 months prior to admission. The measure is currently

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publicly reported by CMS for those patients 65 years and older who are Medicare FFS beneficiaries admitted to non-federal hospitals. Additional details are provided in S.9 Denominator Details.


Exclusions The readmission measures exclude index admissions for patients: 1. Without at least 30 days post-discharge enrollment in FFS Medicare. 2. Discharged against medical advice (AMA); 3. Admitted within 30 days of a prior index admission.

DSRIP Specified Setting Hospital



Additional Notes

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BUNDLE B1: CARE TRANSITIONS & HOSPITAL READMISSIONS

B1-124: Medication Reconciliation Post-Discharge Measure Description:

The percentage of discharges for patients 18 years of age and older for whom the discharge medication

list was reconciled with the current medication list in the outpatient medical record by a prescribing

practitioner, clinical pharmacist or registered nurse.


NQF Number 0097



Measure Parts 1


Numerator Description Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on or within 30 days of discharge. Medication reconciliation is defined as a type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record.

Denominator Description All discharges from an in-patient setting for patients who are 18 years and older.


Exclusions The following exclusions are applicable to the Health Plan Level measure. - Exclude both the initial discharge and the readmission/direct transfer discharge if the readmission/direct transfer discharge occurs after December 1 of the measurement year. - If the discharge is followed by a readmission or direct transfer to an acute or non-acute facility within the 30-day follow-up period, count only the readmission discharge or the discharge from the facility to which the patient was transferred.




Additional Notes

CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; MACRA MIPS High

Priority Measure.

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B1-141: Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) for selected conditions: heart failure hospitalization, coronary artery bypass graft (CABG) surgery, CHF, Diabetes, AMI, Stroke, COPD, Behavioral Health, Substance Use (BAT Recommends a Measure Description:

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) for patients

discharged from the hospital with a principal diagnosis of heart failure (HF). The outcome (readmission)

is defined as unplanned readmission for any cause within 30 days of the discharge date for the index

admission (the admission included in the measure cohort). A specified set of planned readmissions do

not count in the readmission outcome. The target population is patients 18 and over.


NQF Number 0330 / 2515 / other

Measure Steward CMS


Measure Parts 1


Numerator Description TBD

Denominator Description TBD

Inclusions TBD

Exclusions TBD




Additional Notes BAT Recommends a Standardized Risk Adjusting Methodololgy for all providers in DY7 - DY8

CMS Alignment: CMS Consensus Core Set: Cardiovascular Measures;

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B1-217: Risk Adjusted All-Cause Readmission Measure Description:

Risk adjusted rate of hospital admissions (stays) for with a subsequent readmission for any reason within

30 days of discharge for patients 18 years of age and older.

A readmission is a subsequent hospital admission in the same hospital within 30 days following an

original admission. The discharge date for the index admission must occur within the time period

defined as one month prior to the beginning of the measurement period and ending one month prior to

the end of the measurement year to allow for the 30-day follow-up period for readmissions within the

measurement year.


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year The Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.

Denominator Description Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. The Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.



DSRIP Specified Setting Inpatient

Data Source Administrative Claims, Electronic Medical Records


Additional Notes BAT Recommends a Standardized Risk Adjusting Methodololgy for all providers in DY7 - DY8

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B1-252: Care Transition: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges to Ambulatory Care [Home/Self Care] or Home Health Care) Measure Description:

Percentage of patients, regardless of age, discharged from an emergency department (ED) to

ambulatory care or home health care, or their caregiver(s), who received a transition record at the time

of ED discharge including, at a minimum, all of the specified elements


NQF Number 0649

Measure Steward AMA


Measure Parts 1


Numerator Description Patients or their caregiver(s) who received a transition record at the time of emergency department (ED) discharge including, at a minimum, all of the following elements: •Summary of major procedures and tests performed during ED visit, AND •Principal clinical diagnosis at discharge which may include the presenting chief complaint, AND •Patient instructions, AND •Plan for follow-up care (OR statement that none required), including primary physician, other health care professional, or site designated for follow-up care, AND •List of new medications and changes to continued medications that patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for each

Denominator Description All patients, regardless of age, discharged from an emergency department (ED) to ambulatory care (home/self care) or home health care


Exclusions Exclusions: Patients who died Patients who left against medical advice (AMA) or discontinued care Exceptions: Patients who declined receipt of transition record Patients for whom providing the information contained in the transition record would be prohibited by state or federal law




Additional Notes

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B1-253: Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care) Measure Description:

Percentage of patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or

observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, or their

caregiver(s), who received a transition record (and with whom a review of all included information was

documented) at the time of discharge including, at a minimum, all of the specified elements


NQF Number 0647

Measure Steward AMA


Measure Parts 1


Numerator Description Patients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements: Inpatient Care • Reason for inpatient admission, AND • Major procedures and tests performed during inpatient stay and summary of results, AND • Principal diagnosis at discharge Post-Discharge/ Patient Self-Management • Current medication list, AND • Studies pending at discharge (eg, laboratory, radiological), AND • Patient instructions Advance Care Plan • Advance directives or surrogate decision maker documented OR Documented reason for not providing advance care plan Contact Information/Plan for Follow-up Care • 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND • Contact information for obtaining results of studies pending at discharge, AND • Plan for follow-up care, AND • Primary physician, other health care professional, or site designated for follow-up care

Denominator Description All patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care.


Exclusions Patients who died. Patients who left against medical advice (AMA) or discontinued care.

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Additional Notes

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B1-287: Documentation of Current Medications in the Medical Record Measure Description:

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to

documenting a list of current medications using all immediate resources available on the date of the

encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and

vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage,

frequency and route of administration


NQF Number 0419

Measure Steward CMS


Measure Parts 1


Numerator Description The Numerator statement for the most recent versions of the measure is as follows (for both the 2016 Claims and Registry version and the 2017 e Measure version): Eligible professional attests to documenting, updating, or reviewing a patient´s current medications using all immediate resources available on the date of the encounter. This list must include ALL prescriptions, over-the counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency, and route of administration

Denominator Description The 2016 Claims and Registry denominator statement is as follows: “All visits for patients aged 18 years and older.” The 2017 eMeasure denominator statement is as follows: “All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period.”


Exclusions The 2016 Claims and Registry version contains the following Other Performance Exclusion: Eligible professional attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible professional. A patient is not eligible if the following reason is documented: the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status The eMeasure includes the following denominator exception: Medical Reason: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.

DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Hospital, Behavioral Health Outpatient

Data Source Claims (Only), Electronic Health Record (Only), Registry


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Additional Notes

MACRA MIPS High Priority Measure.

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B1-351: INR Monitoring for individuals on warfarin after hospital discharge, Measure Description:

Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and

discharged with a non-therapeutic International Normalized Ratio (INR) who had an INR test within 14

days of hospital discharge


NQF Number 2732

Measure Steward CMS


Measure Parts 1


Numerator Description Individuals in the denominator who had an INR test within 14 days of discharge

Denominator Description Adult inpatient discharges to home for which the individual had active warfarin therapy within 1 day prior to discharge and the last monitored INR within 7 days of discharge was <=1.5 or >= 4


Exclusions The following inpatient discharges are excluded from the denominator. The following exclusion is identified from the Medication Administration Record (MAR) within the patient’s EHR. 1) Inpatient discharges for which the individuals received dabigatran, rivaroxaban, or apixaban within one day prior to discharge The following exclusions are identified from Part A and Part B Medicare Administrative Claims. 2) Inpatient discharges for which the individuals are monitoring INR at home 3) Inpatient discharges for which the individuals expired within 14 days post-discharge 4) Inpatient discharges for which the individuals received hospice care within 14 days post-discharge 5) Inpatient discharges for which the individuals had a hospital inpatient admission within 14 days post-discharge 6) Inpatient discharges for which the individuals were admitted to a skilled nursing facility (SNF) within 14 days post-discharge 7) Inpatient discharges for which the end date of the 14-day follow-up period occurs after the end of the measurement period 8) Inpatient discharges for which the individual is not enrolled in Medicare Part A and Part B at the time of discharge and during the 14-day follow-up period post discharge.


Data Source Claims (Only), Electronic Health Record (Only), Laboratory, Other, Pharmacy


Additional Notes

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BUNDLE B2: PATIENT NAVIGATION & ED DIVERSION

B2-242: Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) Measure Description:

Rate of Emergency Department (ED) utilization for ACSC:

- Grand mal status and other epileptic convulsions

- Chronic obstructive pulmonary diseases

- Asthma

- Heart failure and pulmonary edema

- Hypertension

- Angina, or

- Diabetes


NQF Number NA



Measure Parts 1


Numerator Description Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period


Inclusions Any ED visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period: Grand mal status and other epileptic convulsions: 345 Chronic obstructive pulmonary diseases: 466.0 (only with secondary diagnosis of 491, 492, 494, 496), 491, 492, 494, 496 Asthma: 493 Heart failure and pulmonary edema: 402.01, 402.11, 402.91, 428, 518.4 Hypertension: 401.0, 401.9, 402.00, 402.10, 402.90 Angina: 411.1, 411.8, 413 Diabetes: 250.0, 250.1, 250.2, 250.3,250.8, 250.9

Exclusions The following diagnostic codes should be excluded: Grand mal status and other epileptic convulsions: None Chronic obstructive pulmonary diseases: None

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Asthma: None Heart failure and pulmonary edema: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 Hypertension: procedures: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 Angina: Procedure codes 01-86.99 Diabetes: Diabetes with renal manifestations [250.4], diabetes with ophthalmic manifestations [250.5], diabetes with neurological manifestations [250.6] and diabetes with peripheral circulatory disorders [250.7]




Additional Notes

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B2-246: Reduce Emergency Department visits for Selected Condition or Conditions: CHF, Diabetes, Angina/Hypertension, Behavioral Health & Substance Abuse, COPD, or Dental Measure Description:

Rate of ED utilization for selected preventable conditions or complications. Providers will select one or

more targeted conditions from the approved list.


NQF Number NA



Measure Parts 1


Numerator Description Rate of ED utilization for selected preventable conditions or complications. Providers will select one or more targeted conditions from the approved list.

Denominator Description Total number of ED Visits with a primary or secondary diagnosis of selected condition for any individual 18 years and older during the measurement period

Inclusions Various

Exclusions Various




Additional Notes

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B2-250: Reduce low acuity ED visits Measure Description:

Rate of ED utilization among low acuity presenting patients


NQF Number NA

Measure Steward AHRQ


Measure Parts 1


Numerator Description Total number of patients triaged as low acuity (ESI 3, 4 or 5) and receives treatment in the Emergency Department during the measurement period

Denominator Description Total number of patients triaged as low acuity (ESI 3, 4 or 5) upon presentation to the Emergency Department during the measurement period

Inclusions Denominator: Patients triaged as low acuity (ESI 3, 4 or 5) upon presentation to the Emergency Department during the measurement period Numerator: Acuity scores of 3, 4,and 5 are assessed using the Emergency Severity Index: http://www.ahrq.gov/professionals/systems/hospital/esi/esi4.html





Additional Notes

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B2-251: Emergency department (ED) visits where patients left without being seen Measure Description:

The percentage of patients presenting to the emergency department (ED) who did not wait after having

clinical information documented about their presenting complaint, during the measurement period.


NQF Number NA

Measure Steward Australian Council on Healthcare Standards


Measure Parts 1


Numerator Description Number of patients presenting to the emergency department (ED) who did not wait* after having clinical information documented** about their presenting complaint, during the time period

Denominator Description Total number of patients presenting to the emergency department (ED), during the time period

Inclusions *Did not wait is defined as any person who leaves before treatment is commenced by a clinician. A diagnosis is not required. **Documentation of clinical information is defined as an entry in either the medical record or emergency department information system that indicates that the patient provided information about their presenting complaint to a clinician during the triage process.



Data Source Electronic Health Record, Clinical Data, Registration data


Additional Notes

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B2-352: Heart Failure: Post-Discharge Appointment for Heart Failure Patients Measure Description:

2455: Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care

or home health care with a principal discharge diagnosis of heart failure for whom a follow up

appointment was scheduled and documented prior to discharge (as specified)

2439: Patients for whom a follow-up appointment for an office or home health visit for management of

heart failure was scheduled within 7 days post-discharge and documented including location, date, and

time.


NQF Number 2455 & 2439 (BAT Reccomendation to modify for additional conditions)

Measure Steward 2455: AHA/ASA, 2439: TJC


Measure Parts 2


Numerator Description 2455: Patients for whom a follow up appointment was scheduled and documented prior to discharge including either: - an office visit for management for heart failure with a physician OR advanced practice nurse OR physician assistant OR - a home health visit for management of heart failure 2439: Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Denominator Description 2455: All patients, regardless of age, discharged from an inpatient facility (ie, hospital inpatient or observation) to ambulatory care (home/self care) of home health care with a principle discharge diagnosis of heart failure 2439: All heart failure patients discharged from a hospital inpatient setting to home or home care.


Exclusions 2455: Denominator exclusions include: Patient was discharged to a health care facility for hospice care, to home for hospice care, or to a rehabilitation facility. Patient left against medical advice. Patient expired. Denominator exceptions include: Documentation of medical reason(s) for not documenting that a follow up appointment was scheduled Documentation of patient reason(s) for not documenting that a follow up appointment was scheduled (eg, international patients, patients from state and/or local corrections facilities for whom scheduling the appointment is prohibited) 2439: Excluded Populations:

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• Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A, Table 2.2) • Patients less than 18 years of age • Patient who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in a Clinical Trial • Patients discharged to locations other than home, home care, or law enforcement • Patients with a documented Reason for No Post-Discharge Appointment Within 7 Days • Patients who left against medical advice (AMA)


Data Source 2455: Registry 2439: Electronic Health Record (Only), Paper Records


Additional Notes BAT recommendation to expand to principle diagnosis of Diabetic Ketoacidosis, CAD, COPD, and to specify post-discharge appointment scheduled prior to discharge or the end of the next business day if discharge was completed outside of business hours

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B2-353: Proportion of Children with ED Visits for Asthma with Evidence of Primary Care Connection Before the ED Visit Measure Description:

This measure describes the incidence rate of emergency department visits for children ages 2 to 21 who

are being managed for identifiable asthma. This measure characterizes care that precedes Emergency

Department visits for children ages 2- 21 who can be identified as having asthma, using the specified

definitions. The developers sought to identify children with ongoing asthma who should be able to be

identified by their healthcare providers and/or healthcare plans as having asthma. The operational

definition of an identifiable asthmatic is a child who has utilized healthcare services that suggest the

healthcare system has enough information to conclude that the child has an asthma diagnosis that

requires ongoing care. Specifically, this measure identifies the use of primary care services and

medications prior to ED visits and/or hospitalizations for children with asthma.


NQF Number 3170 (Under Review)

Measure Steward University Hospitals Cleveland Medical Center

Link to Measure Citation

Measure Parts 1


Numerator Description Evidence of connection to the primary care medical system prior to first ED visit and/or hospitalization that has a primary or secondary diagnosis of asthma among children whom our specifications identify with asthma.

Denominator Description All first ED visits and/or hospitalizations, in which asthma was a primary or secondary diagnosis in children age 2-21 who meet criteria for being managed for identifiable asthma in the assessment period and have been enrolled for the 6 consecutive months prior to the ED visit/admission.






Additional Notes

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B2-354: Post-discharge evaluation for heart failure patients (BAT recommendation to expand to principle diagnosis of Diabetic Ketoacidosis, CAD, and COPD) Measure Description:

Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a program

team member within 72 hours after inpatient discharge.


NQF Number 2443

Measure Steward The Joint Commission


Measure Parts 1


Numerator Description Patients who have a documented re-evaluation conducted via phone call or home visit within 72 hours after discharge.

Denominator Description All heart failure patients discharged from a hospital inpatient setting to home or home care AND patients leaving against medical advice (AMA).


Exclusions Excluded Populations: • Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A, Table 2.2) • Patients less than 18 years of age • Patient who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in a Clinical Trial • Patients discharged to locations other than home, home care or law enforcement.


Data Source Electronic Health Record (Only), Paper Records


Additional Notes BAT recommendation to expand to principle diagnosis of Diabetic Ketoacidosis, CAD, and COPD

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BUNDLE C1: PRIMARY CARE PREVENTION - HEALTHY TEXANS

C1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention Measure Description:

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times

within 24 months AND who received cessation counseling intervention if identified as a tobacco user


NQF Number 0028



Measure Parts 1


Numerator Description Patients who were screened for tobacco use* at least once within 24 months AND who received tobacco cessation counseling intervention** if identified as a tobacco user *Includes use of any type of tobacco ** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy

Denominator Description All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period


Exclusions Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy)

DSRIP Specified Setting Behavioral Health: Outpatient, Primary Care, Outpatient Specialty Care, other

Data Source Claims (Only), Electronic Health Record (Only), Other, Paper Records, Registry


Additional Notes BAT recommendation to stratify as two rates, ages 18+ and 12 - 17

CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; CMS Consensus Core

Set: Cardiovascular Measures; MACRA MIPS Measure; CCBHC Measure.

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C1-113: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received an HbA1c



NQF Number 0057



Measure Parts 1


Numerator Description Patients who had an HbA1c test performed during the measurement year.







Additional Notes


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C1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Measure Description:




Normal Parameters:


Age 18 – 64 years BMI >= 18.5 and < 25



Measure Steward CMS


Measure Parts 1






DRAFT

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Data Source Other


Additional Notes



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C1-268: Pneumonia vaccination status for older adults Measure Description:

Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.


NQF Number 0043

Measure Steward CMS


Measure Parts 1


Numerator Description The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine."

Denominator Description CAHPS respondents age 65 or older as of the last day of the measurement year who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”






Additional Notes

MACRA MIPS Measure. DRAFT

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C1-269: Preventive Care and Screening: Influenza Immunization Measure Description:

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who

received an influenza immunization OR who reported previous receipt of an influenza immunization



Measure Steward AMA / PCPI


Measure Parts 1


Numerator Description Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization

Denominator Description All patients aged 6 months and older seen for a visit between October 1 and March 31


Exclusions Documentation of medical reason(s) for not receiving influenza immunization (eg, patient allergy, other medical reasons) Documentation of patient reason(s) for not receiving influenza immunization (eg, patient declined, other patient reasons) Documentation of system reason(s) for not receiving influenza immunization (eg, vaccine not available, other system reasons)

DSRIP Specified Setting Primary Care

Data Source Electronic Health Record (Only), Registry


Additional Notes

MACRA MIPS Measure.

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C1-272: Adults (18+ years) Immunization status Measure Description:

Percentage of adult patients 18 years and older who are up-to-date with the following immunizations:

-One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years

-Varicella – two doses or history of disease up to year 1995

-Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older

-One influenza within last year

-Herpes zoster/shingles (patients 60 years and older)


NQF Number NA

Measure Steward Institute for Clinical Systems Improvement


Measure Parts 1


Numerator Description Number of patients who are up-to-date with following immunizations: -One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years -Varicella – two doses or history of disease up to year 1995 -Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older -One influenza dose within the last year -Herpes zoster/shingles (patients 60 years and older)

Denominator Description Number of patients 18 years and older during the specified measurement period*


Exclusions Denominator Exclusions: Patients with immunization contraindications listed in the medical record should be excluded


Data Source Clinical Data, Electronic Health Record, Administrative Claims


Additional Notes

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C1-280: Chlamydia Screening in Women (CHL) Measure Description:

The percentage of women 16–24 years of age who were identified as sexually active and who had at

least one test for chlamydia during the measurement year.


NQF Number 0033



Measure Parts 1


Numerator Description Females who were tested for chlamydia during the measurement year.

Denominator Description Females 16-24 years who had a claim or encounter indicating sexual activity.


Exclusions Females who received a pregnancy test to determine contraindications for medication (isotretinoin) or x-ray.


Data Source Claims (Only), Electronic Health Record (Only), Imaging-Diagnostic, Laboratory, Pharmacy


Additional Notes

CMS Alignment: Child Core Set; MACRA MIPS Measure. DRAFT

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C1-285: Advance Care Plan Measure Description:

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision

maker documented in the medical record or documentation in the medical record that an advance care

plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or

provide an advance care plan.


NQF Number 0326



Measure Parts 1


Numerator Description Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Denominator Description All patients aged 65 years and older.



DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Hospital

Data Source Claims (Only), Electronic Health Record (Only)


Additional Notes

MACRA MIPS High Priority Measure. DRAFT

PREVIEW



C1-389: Human Papillomavirus Vaccine (age 14 -26) Measure Description:

TBD


NQF Number

Measure Steward 0

Link to Measure Citation TBD

Measure Parts 1







Data Source TBD


Additional Notes

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BUNDLE C2: PRIMARY CARE PREVENTION - CANCER SCREENING & FOLLOW-

UP

C2-106: Cervical Cancer Screening Measure Description:

Percentage of women 21–64 years of age who were screened for cervical cancer using either of the

following criteria:

- Women age 21–64 who had cervical cytology performed every 3 years.

- Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every

5 years.


NQF Number 0032



Measure Parts 1


Numerator Description The number of women who were screened for cervical cancer.

Denominator Description Women 24-64 years of age as of the end of the measurement year.


Exclusions Exclude: Women who had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during their medical history through the end of the measurement year.




Additional Notes


Consensus OB/GYN Measures; MACRA MIPS Measure; Proposed 2018 MCO P4Q Measure.

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C2-107: Colorectal Cancer Screening Measure Description:

The percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer.


NQF Number 0034



Measure Parts 1


Numerator Description One or more screenings for colorectal cancer. Any of the following meet criteria: - Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type. - Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year. - Colonoscopy during the measurement year or the nine years prior to the measurement year.

Denominator Description Patients 51–75 years of age as of the end of the measurement year.


Exclusions Exclude patients with a diagnosis of colorectal cancer or total colectomy


Data Source Claims (Only), Imaging-Diagnostic, Laboratory, Paper Records


Additional Notes


Measure.

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C2-162: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Measure Description:

Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or

polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy

documented in their colonoscopy report.


NQF Number 0658

Measure Steward American Gastroenterological Association


Measure Parts 1


Numerator Description Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

Denominator Description All patients aged 50 years and older and receiving screening a screening colonoscopy without biopsy or polypectomy


Exclusions Documentation of medical reason(s) for not recommending at least a 10 year follow-up interval (eg, inadequate prep, other medical reasons)

DSRIP Specified Setting Clinician Office/Clinic

Data Source Claims (Only), Electronic Health Record (Only), Imaging-Diagnostic, Other, Registry


Additional Notes

CMS Alignment: CMS Consensus Core Set: Gastroenterology Measures; MACRA MIPS High Priority

Measure.

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C2-186: Breast Cancer Screening Measure Description:

The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.


NQF Number 2372



Measure Parts 1


Numerator Description Women who received a mammogram to screen for breast cancer.

Denominator Description Women 52-74 years as of December 31 of the measurement year Note: this denominator statement captures women age 50-74 years; it is structured to account for the look-back period for mammograms.


Exclusions Bilateral mastectomy any time during the member’s history through December 31 of the measurement year. Any of the following meet criteria for bilateral mastectomy: 1) Bilateral mastectomy 2) Unilateral mastectomy with a bilateral modifier 3) Two unilateral mastectomies on different dates of service and 4) Both of the following (on the same date of service): Unilateral mastectomy with a right-side modifier and unilateral mastectomy with a left-side modifier.




Additional Notes


Consensus OB/GYN Measures; MACRA MIPS Measure.

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C2-199: PQRS #439: Age Appropriate Screening Colonoscopy Measure Description:

The percentage of patients greater than 85 years of age who received a screening colonoscopy from

January 1 to December 31


NQF Number NA


Link to Measure Citation https://pqrs.cms.gov/dataset/2016-PQRS-Measure-439-11-17-2015/c5y7-sabu

Measure Parts 1


Numerator Description All patients greater than 85 years of age included in the denominator who did NOT have a history of colorectal cancer or a valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e. regional enteritis), familial adenomatous polyposis, Lynch Syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal findings of gastrointestinal tract, or changes in bowel habits. Colonoscopy examinations performed for screening purposes only. Numerator Instructions: INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control, and therefore an inverse measure at 100% does not qualify for reporting purposes, however any reporting rate less than 100% does qualify.

Denominator Description Colonoscopy examinations performed on patients greater than 85 years of age during the encounter period Denominator Instructions: Clinicians who indicate that the colonoscopy procedure is incomplete or was discontinued should use the procedure number and the addition (as appropriate) of modifier 52, 53, 73, or 74. Patients who have a coded colonoscopy procedure that has a modifier 52, 53, 73, or 74 will not qualify for inclusion in this measure. Denominator Criteria (Eligible Cases): All patients greater than 85 years of age on date on encounter receiving a colonoscopy for screening purposes only AND

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https://pqrs.cms.gov/dataset/2016-PQRS-Measure-439-11-17-2015/c5y7-sabu

https://pqrs.cms.gov/dataset/2016-PQRS-Measure-439-11-17-2015/c5y7-sabu


Patient encounter during the reporting period (CPT or HCPCS): 45378, 45380, 45381, 45384, 45385, G0121


Exclusions Performance Not Met: Documentation of medical reason(s) for a colonoscopy performed on a patient greater than 85 years of age (e.g., last colonoscopy incomplete, last colonoscopy had inadequate prep, iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e., regional enteritis), familial history of adenomatous polyposis, Lynch Syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits) (G9660) OR Performance Not Met: Patients greater than 85 years of age who received a routine colonoscopy for a reason other than the following: an assessment of signs/symptoms of GI tract illness, and/or the patient is considered high risk, and/or to follow-up on previously diagnoses advance lesions (G9661)


Data Source Not listed


Additional Notes

CMS Alignment: CMS Consensus Core Set: Gastroenterology Measures; MACRA MIPS High Priority

Measure.

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C2-274: Mammography follow-up rate Measure Description:

This measure is used to assess the percentage of patients with mammography screening studies that are

followed by a diagnostic mammography, ultrasound or magnetic resonance imaging (MRI) of the breast

in an outpatient or office setting within 45 days.


NQF Number NA

Measure Steward CMS


Measure Parts 1


Numerator Description Of studies identified in the denominator, the number of studies with diagnostic mammography, ultrasound, or magnetic resonance imaging (MRI) of the breast (i.e., within 45, of the screening mammography study) (see the related "Numerator Inclusions/Exclusions" field)

Denominator Description The number of patients who had received a screening mammography study (see the related "Denominator Inclusions/Exclusions" field)

Inclusions Numerator Inclusions: Of studies identified in the denominator, the number of studies with diagnostic mammography, ultrasound, or magnetic resonance imaging (MRI) of the breast (i.e., within 45 days, of the screening mammography) Note: The numerator measurement of a diagnostic mammography, ultrasound or MRI study is based on the claim date of the screening mammography from the denominator. The 45-day time window includes the same day that the screening was performed; that is, the numerator would include diagnostic mammography or ultrasound on the same day as the screening mammogram. Medicare will reimburse for both the screening mammography and diagnostic mammography procedures for a screening mammogram and a diagnostic mammogram performed on the same patient on the same day (section 4601.2 [I] of the Medicare Carriers Manual - Transmittal #1724). Refer to the original measure documentation for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. Denominator Inclusions: The number of patients who had received a screening mammography study Note: Initial Patient Population: This measure applies only to Medicare beneficiaries enrolled in original, fee-for-service (FFS) Medicare who were treated as outpatients in hospital facilities reimbursed through the Outpatient Prospective Payment System (OPPS). These measures do not include Medicare managed care beneficiaries, non-Medicare patients, or beneficiaries who were admitted to the hospital as inpatients.

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Beneficiaries included in the measure's initial patient population had documentation of a mammography screening performed from July 1 through May 15 during the measurement period. Beneficiaries can be included in the measure's initial patient population multiple times; each mammography screening performed at a facility measured by OPPS is counted once in the measure's denominator. Refer to the original measure documentation for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.



Data Source Administrative clinical data


Additional Notes

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C2-275: Abnormal Pap test follow-up rate Measure Description:

Percentage of women aged 12 to 65 years old who undergo follow‐up colposcopy after a Pap test

identification of high‐grade squamous intraepithelial lesions (HSIL), atypical squamous cells (ASC‐H),

atypical glandular cells (AGC), or cancer‐in‐situ.


NQF Number NA

Measure Steward American College of Obstetrics and Gynecology


Measure Parts 1


Numerator Description The number of women aged 12 to 65 years old who undergo follow‐up colposcopy after a Pap test identification of high‐grade squamous intraepithelial lesions (HSIL), atypical squamous cells (ASC‐H), atypical glandular cells (AGC), or cancer‐in‐situ.

Denominator Description The number of women aged 12 to 65 years old with a Pap test identification of high‐grade squamous intraepithelial lesions (HSIL), atypical squamous cells (ASC‐H), atypical glandular cells (AGC), or cancer‐in‐situ.




Data Source Administrative/Clinical data sources


Additional Notes

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BUNDLE C3: HEPATITIS C

C3-202: PQRS #401: Screening for Hepatocellular Carcinoma (HCC) in Patients with Hepatitis C Cirrhosis Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who

underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma

(HCC) at least once within the 12 month reporting period


NQF Number NA


Link to Measure Citation https://pqrs.cms.gov/dataset/2016-PQRS-Measure-401-11-17-2015/xgtb-359z

Measure Parts 1


Numerator Description Patients who underwent abdominal imaging with either ultrasound, contrast enhanced CT or MRI

Denominator Description All patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis

Inclusions Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Diagnosis for chronic hepatitis C (ICD-10-CM): B18.2, B19.20, B19.21 AND Diagnosis for cirrhosis (ICD-10-CM): K70.30, K70.31, K74.60, K74.69 AND Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 Numerator: Performance Met: Patient underwent abdominal imaging with ultrasound, contrast enhanced CT or contrast MRI for HCC (G9455)

Exclusions Numerator: Other Performance Exclusion: Documentation of medical or patient reason(s) for not ordering or performing screening for HCC. Medical reason: Comorbid medical conditions with expected survival <5 years, hepatic decompensation and not a candidate for liver transplantation, or other medical reasons. Patient reasons: Patient declined or other patient reasons (e.g., cost of tests, time related to accessing testing equipment) (G9456) OR

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https://pqrs.cms.gov/dataset/2016-PQRS-Measure-401-11-17-2015/xgtb-359z

https://pqrs.cms.gov/dataset/2016-PQRS-Measure-401-11-17-2015/xgtb-359z


Performance Not Met: Patient did not undergo abdominal imaging and did not have a documented reason for not undergoing abdominal imaging in the reporting period (G9457)


Data Source Not listed


Additional Notes BAT recommendation that denominator is specific to individuals managming treatment for HCV in a primary care setting (not specialty care)

CMS Alignment: CMS Consensus Core Set: Hep C Core Measures; MACRA MIPS Measure.

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C3-203: PQRS #400: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Measure Description:

Percentage of patients aged 18 years and older with one or more of the following: a history of injection

drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate

in the years 1945–1965 who received one- time screening for hepatitis C virus (HCV) infection


NQF Number NA / 3059 eMeasure

Measure Steward AMA-PCPI

Link to Measure Citation https://pqrs.cms.gov/dataset/2016-PQRS-Measure-400-11-17-2015/kx88-j5sg http://www.qualityforum.org/QPS/3059

Measure Parts 1


Numerator Description Patients who received one-time screening for HCV infection

Denominator Description All patients aged 18 years and older who were seen twice for any visit or who had at least one preventive visit within the 12 month reporting period with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965


Exclusions Denominator Exclusions: Patients with a diagnosis of chronic hepatitis C Denominator Exceptions: Documentation of medical reason(s) for not receiving one-time screening for HCV infection (eg, decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) Documentation of patient reason(s) for not receiving one-time screening for HCV infection (eg, patient declined, other patient reasons)


Data Source Electronic Health Record (Only), Other


Additional Notes


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https://pqrs.cms.gov/dataset/2016-PQRS-Measure-400-11-17-2015/kx88-j5sg




C3-311: PQRS #390 Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or

other qualified healthcare professional reviewed the range of treatment options appropriate to their

genotype and demonstrated a shared decision making approach with the patient. To meet the measure,

there must be documentation in the patient record of a discussion between the physician or other

qualified healthcare professional and the patient that includes all of the following: treatment choices

appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward

treatment


NQF Number NA


Link to Measure Citation https://pqrs.cms.gov/dataset/2016-PQRS-Measure-390-11-17-2015/2dh2-wj4r

Measure Parts 1


Numerator Description Patients with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient

Denominator Description All patients aged 18 years and older with a diagnosis of chronic hepatitis C

Inclusions Denominator: Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Diagnosis for chronic hepatitis C (ICD-10-CM): B18.2, B19.20, B19.21 AND Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 Numerator: Numerator Options: Performance Met: Documentation in the patient record of a discussion between the physician/clinician and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward the outcome of the treatment (G9399)

Exclusions Numerator: Other Performance Exclusion: Documentation of medical or patient reason(s) for not discussing treatment options. Medical reasons: Patient is not a candidate for treatment due to advanced physical or mental health comorbidity (including active substance use); currently

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https://pqrs.cms.gov/dataset/2016-PQRS-Measure-390-11-17-2015/2dh2-wj4r

https://pqrs.cms.gov/dataset/2016-PQRS-Measure-390-11-17-2015/2dh2-wj4r


receiving antiviral treatment; successful antiviral treatment (with sustained virologic response) prior to reporting period; other documented medical reasons. Patient reasons: Patient unable or unwilling to participate in the discussion or other patient reasons (G9400) No documentation of a discussion in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment (G9401)


Data Source None listed


Additional Notes


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C3-328: Appropriate Screening Follow-up for Patients Identified with Hepatitis C Virus (HCV) Infection (eMeasure) Measure Description:

Percentage of patients aged 18 years and older with either (1) a positive HCV antibody test result and a

positive HCV RNA test result 1or (2) a positive HCV antibody test result and an absent HCV RNA test

result who are prescribed treatment or are referred to evaluation or treatment services


NQF Number 3061 (Approved for Trial Use)

Measure Steward PCPI


Measure Parts 1


Numerator Description Patients who are prescribed treatment or are referred to evaluation or treatment services

Denominator Description All patients aged 18 years and older who are seen twice for any visit or who had at least one preventive visit with either (1) a positive HCV antibody test result and a positive HCV RNA test result or (2) a positive HCV antibody test result and an absent HCV RNA test result


Exclusions Denominator Exclusions: Patients with a negative HCV RNA result, patients with a diagnosis of chronic hepatitis C Denominator Exceptions: Documentation of medical reason(s) for not prescribing treatment or being referred to evaluation or treatment services (eg, participation in a clinical trial, decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) Documentation of patient reason(s) for not prescribing treatment or being referred to evaluation or treatment services (eg, patient declined, other patient reasons)




Additional Notes

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C3-368: Hepatitis C: Hepatitis A Vaccination Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least

one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A


NQF Number 0399



Measure Parts 1


Numerator Description Patients who have received at least one injection of hepatitis A vaccine, or who have documented immunity to Hepatitis A

Denominator Description All patients aged 18 years and older with a diagnosis of chronic hepatitis C


Exclusions Documentation of medical reason(s) for not administering at least one injection of hepatitis A vaccine (eg, allergy or intolerance to a known component of the vaccine, other medical reasons) Documentation of patient reason(s) for not administering at least one injection of hepatitis A vaccine (eg, patient declined, insurance coverage, other patient reasons)


Data Source Electronic Health Record (Only), Laboratory, Other, Registry


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C3-369: Hepatitis C: Hepatitis B Vaccination Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least

one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B


NQF Number 0400

Measure Steward AMA-convened Physician Consortium for Performance Improvement


Measure Parts 1


Numerator Description Patients who have received at least one injection of Hepatitis B vaccine, or who have documented immunity to Hepatitis B

Denominator Description All patients aged 18 years and older with a diagnosis of hepatitis C


Exclusions Documentation of medical reason(s) for not receiving at least one injection of hepatitis B vaccine Documentation of patient reason(s) for not receiving at least one injection of hepatitis B vaccine


Data Source Claims (Only), Electronic Health Record (Only), Laboratory, Other, Registry



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BUNDLE D1: PEDIATRIC PRIMARY CARE

D1-108: Childhood Immunization Status (CIS) Measure Description:

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP);

three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB);

three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A

(HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The

measure calculates a rate for each vaccine.


NQF Number 0038



Measure Parts 1


Numerator Description Children who have evidence showing they received all recommended vaccines by their second birthday: • Four diphtheria, tetanus and acellular pertussis (DtaP) • Three polio (IPV) • One measles, mumps and rubella (MMR) • Three H influenza type B (HiB) • Three hepatitis B (HepB) • One chicken pox (VZV) • Four pneumococcal conjugate (PCV) • One hepatitis A (HepA) • Two or three rotavirus (RV); and, • Two influenza (flu)

Denominator Description Children who turn 2 years of age during the measurement year.


Exclusions Exclude children who had a contraindication for a specific vaccine from the denominator for all antigen rates. The denominator for all rates must be the same.


Data Source Claims (Only), Electronic Health Record (Only), Paper Records, Registry


Additional Notes

CMS Alignment: Child Core Set; MACRA MIPS Measure; Proposed 2018 MCO P4Q Measure.

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D1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Measure Description:

Percentage of children 3-17 years of age who had an outpatient visit with a primary care physician (PCP)

or an OB/GYN and who had evidence of:

Rate #1: Body Mass Index (BMI) percentile documentation

Rate #2: Counseling for nutrition, and

Rate #3: Counseling for physical activity.


NQF Number 0024



Measure Parts 3

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: BMI Percentile: 0.8637 Counseling for Nutrition: 0.7952 Counseling for Physical Activity: 0.7158 MPL: BMI Percentile: 0.545 Counseling for Nutrition: 0.5184 Counseling for Physical Activity: 0.4509

Numerator Description Children ages 3-17 with evidence of each of the following: Rate #1: Documented body mass index (BMI) percentile Rate #2: Counseling for nutrition Rate #3: Counseling for physical activity during the measurement year

Denominator Description Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.


Exclusions Exclude patients who have a diagnosis of pregnancy during the measurement year.




Additional Notes

CMS Alignment: Child Core Set; MACRA MIPS Measure; Proposed 2018 MCO P4Q Measure; CCBHC

Measure.

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D1-212: Appropriate Testing for Children With Pharyngitis Measure Description:

The percentage of children 2–18 years of age who were diagnosed with pharyngitis, dispensed an

antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents

better performance (i.e., appropriate testing).


NQF Number 0002



Measure Parts 1


Numerator Description A group A streptococcus test (Group A Strep Tests Value Set) in the seven-day period from three days prior to the Index Episode Start Date (IESD) through three days after the IESD.

Denominator Description Children age 2 years as of July 1 of the year prior to the measurement year to 18 years as of June 30 of measurement year who had an outpatient or ED visit with only a diagnosis of pharyngitis and were dispensed an antibiotic for the episode of care during the 6 months prior to through the 6 months after the beginning of the measurement year.


Exclusions 1) Exclude encounters with more than one diagnosis and ED visits that result in an inpatient admission. 2) Exclude episodes if the patient did not receive antibiotics on or within three days after the date of service. 3) Exclude episodes where a new or refill prescription for an antibiotic medication (Table CWP-C) was filled 30 days prior to the date of service or which was active on the date of service.

DSRIP Specified Setting Primary Care, Urgent Care, Outpatient Specialty Care

Data Source Claims (Only), Laboratory, Pharmacy


Additional Notes

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D1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits) Measure Description:

The percentage of children 15 months old who had the recommended number of well-child visits with a

PCP during their first 15 months of life.


NQF Number 1392



Measure Parts 1


Numerator Description Children who received the following number of well-child visits with a PCP during their first 15 months of life: - No well-child visits - One well-child visit - Two well-child visits - Three well-child visits - Four well-child visits - Five well-child visits - Six or more well-child visits

Denominator Description Children 15 months old during the measurement year.






Additional Notes

CMS Alignment: Child Core Set; Proposed 2018 MCO P4Q Measure.

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D1-238: Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Measure Description:

The percentage of children 3-6 years of age who had one or more well-child visits with a PCP during the

measurement year.


NQF Number 1516



Measure Parts 1


Numerator Description Children who received at least one well-child visit with a PCP during the measurement year.

Denominator Description Children 3-6 years of age during the measurement year.






Additional Notes

CMS Alignment: Child Core Set;

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D1-240: Adolescent Well-Care Visits (AWC) Measure Description:

This measure is used to assess the percentage of enrolled members 12 to 21 years of age who had at

least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrics and

gynecology (OB/GYN) practitioner during the measurement year.


NQF Number NA



Measure Parts 1


Numerator Description At least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrics and gynecology (OB/GYN) practitioner during the measurement year (see the related "Numerator Inclusions/Exclusions" field)

Denominator Description Members age 12 to 21 years as of December 31 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)

Inclusions Denominator: Members age 12 to 21 years as of December 31 of the measurement year Note: Members must have been continuously enrolled during the measurement year. Allowable Gap: No more than one gap in enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid member for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage. Numerator: At least one comprehensive well-care visit (Well-Care Value Set) with a primary care practitioner (PCP) or an obstetrics and gynecology (OB/GYN) practitioner during the measurement year. The practitioner does not have to be the practitioner assigned to the member.



Data Source Administrative clinical data, Paper medical record


Additional Notes


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D1-271: Immunization for Adolescents- Tdap/TD and MCV Measure Description:

The percentage of adolescents 13 years of age who had the recommended immunizations

(meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or

one tetanus, diphtheria toxoids vaccine (Td)) by their 13th birthday.


NQF Number 1407



Measure Parts 1


Numerator Description Adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.

Denominator Description Adolescents who turn 13 years of age during the measurement year.


Exclusions Exclude adolescents who had a contraindication for a specific vaccine from the denominator for all antigen rates and the combination rate. The denominator for all rates must be the same. Contraindicated adolescents may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered. Either of the following meet exclusion criteria: • Anaphylactic reaction to the vaccine or its components (Anaphylactic Reaction Due To Vaccination Value Set) any time on or before the member’s 13th birthday. • Anaphylactic reaction to the vaccine or its components (Anaphylactic Reaction Due To Serum Value Set), with a date of service prior to October 1, 2011.




Additional Notes Updated to include HPV

CMS Alignment: Child Core Set; MACRA MIPS Measure.

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D1-284: Appropriate Treatment for Children with Upper Respiratory Infection (URI) Measure Description:

Percentage of children 3 months to 18 years of age with a diagnosis of upper respiratory infection (URI)

who were not dispensed an antibiotic medication.


NQF Number 0069



Measure Parts 1


Numerator Description Patients who were dispensed antibiotic medication on or within 3 days after an outpatient or ED encounter for upper respiratory infection (URI) during the intake period (a higher rate is better). The measure is reported as an inverted rate (i.e. 1- numerator/denominator) to reflect the number of children that were not dispensed an antibiotic.

Denominator Description All children age 3 months as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year who had an ED or outpatient visit with only a diagnosis of nonspecific upper respiratory infection (URI) during the intake period (July 1st of the year prior to the measurement year to June 30th of the measurement year).


Exclusions Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date. Exclude Episode Dates where the patient had a claim/encounter with a competing diagnosis on or three days after the Episode Date.

DSRIP Specified Setting Primary Care, Urgent Care, Outpatient Specialty Care

Data Source Claims (Only), Electronic Health Record (Only), Pharmacy


Additional Notes

MACRA MIPS High Priority Measure; Proposed 2018 MCO P4Q Measure.

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D1-301: Maternal Depression Screening Measure Description:

The percentage of children 6 months of age who had documentation of a maternal depression screening

for the mother.


NQF Number 1401

Measure Steward National Committee for Quality Assurance


Measure Parts 1


Numerator Description Children who had documentation of a maternal depression screening for the mother at least once between 0 and 6 months of life.

Denominator Description Children with a visit who turned 6 months of age in the measurement year.




Data Source Electronic Health Record (Only), Other, Paper Records


Additional Notes

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BUNDLE D3: PEDIATRIC HOSPITAL SAFETY

D3-330: Pediatric CLABSI Measure Description:

This measure answers the question: How often is a patient harmed due to central line associated blood

stream infections?


NQF Number NA

Measure Steward Children’s Hospitals’ Solutions for Patient Safety National Children’s Network

Link to Measure Citation http://www.solutionsforpatientsafety.org/wp-content/uploads/sps-operating-definitions.pdf

Measure Parts 1


Numerator Description Numerator: Number of patients contracting an infection, as defined by CDC guidelines. Multiple infection sites due to the same organism are counted as one infection. For this measure, distinction is not made between an infection due to CVC/PICC insertion and one due to maintenance practices. HEM/ONC patients residing in HEM/ONC units by: CLABSI, Secondary infections, Single positive cultures Number of events outside of HEM/ONC units with MBI, based on geography

Denominator Description Denominator: Total number of central line days during the time period. Two analyses: a) Number of blood stream infections per 1000 central line days (Numerator/Denominator) x 1000 b) Total number of blood stream infections Process Data: Observations collected by unit: PICU, CICU, NICU, Hematology-Oncology and all other units.

Inclusions All patients are included who are defined as inpatient or under observation at the hospital including two calendar days post discharge.

Exclusions Infection must not be incubating at the time of the admission into the hospital. For most infections, this means that the infection does not become evident until two calendar days or more after admission, but each infection must be assessed individually.


Data Source Each hospital will report data using their own collection methods until specific high detection methods are prescribed by the network.


Additional Notes

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http://www.solutionsforpatientsafety.org/wp-content/uploads/sps-operating-definitions.pdf



D3-331: Pediatric CAUTI Measure Description:

This measure answers the question: How often are patients harmed by the occurrence of a catheter

associated urinary tract infections?


NQF Number NA



Measure Parts 1


Numerator Description Events per Catheter Day: Numerator: Number of patients contracting an infection, as defined by CDC guidelines. Catheter Days per Patient Days Numerator: Number of catheter days.

Denominator Description Events per Catheter Day: Denominator: Total number of indwelling urinary catheter days during the time period. Number of urinary tract infections per 1000 urinary catheter days (Numerator/Denominator) x 1000 Catheter Days per Patient Days: Denominator: Total number of patient days (excluding NICU) Number of catheter per 1000 patient days (Numerator/Denominator) x 1000

Inclusions All patients admitted to an inpatient unit are included who are defined as inpatient or under observation at the hospital with an indwelling urinary catheter.

Exclusions Observation patients admitted to observation units and patients admitted to neonatal intensive care units will be excluded. Infection must not be incubating at the time of the admission into the hospital. For most infections, this means that the infection does not become evident until 48 hours or more after admission, but each infection must be assessed individually. There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter associated.




Additional Notes

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D3-333: Pediatric Surgical site infections (SSI) Measure Description:

This measure answers the question: How often is a patient harmed due to surgical site infections in high

risk surgeries? The current version of the National Healthcare Safety Network (NHSN) Manual: Patient

Safety Component Protocol will serve as the official reference guide for rules around reporting surgical

site infections.


NQF Number NA



Measure Parts 1


Numerator Description Number of SSIs related to designated surgical procedures.

Denominator Description Number of patient trips to the operating room for designated surgical procedures during the applicable reporting period. Note: A patient trip to the operating room is counted only once, regardless of the number of procedures performed. (Numerator/Denominator) x 100 (Note: reported as SSIs per 100 patient trips to the operating room.)

Inclusions All patients who experience one of the above surgical procedures

Exclusions Patients with physician/advanced practice nurse/physician assistant of documentation of an active infection at the time of the surgical procedure.

redness/tenderness, elevatSpine refusion procedures will be excluded.


Data Source Each hospital will report data using their own collection methods utilizing the procedure


Additional Notes

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D3-334: Pediatric Adverse Drug Events Measure Description:

This measure answers the question: How often do is a patient harmed due to drugs given to them?

Adverse drug events will be defined per the National Coordinating Council for Medication Error

Reporting and Prevention’s Index for Categorizing Medication Errors.


NQF Number NA



Measure Parts 2


Numerator Description Number of adverse drug events per NCC MERP’s Index for Categorizing Medication Errors. Numerators will be reported as Level E and combined Level F-I as defined below. E = An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention F = An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization G = An error occurred that may have contributed to or resulted in permanent patient harm H = An error occurred that required intervention necessary to sustain life I = An error occurred that contributed to or resulted in the patient’s death

Denominator Description Denominator: Total number patient days. Number adverse drug events in category E per number patient days per 1000 patients (Numerator/Denominator) * 1000 Number of adverse drug events in categories F-I (combined) per number of patient days per 1000 patients (Numerator/Denominator) * 1000

Inclusions All patients are included who are defined as inpatient or under observation at the hospital.



Data Source codes listed in appendix A or other methods that reliably collect the cases listed above.


Additional Notes

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D3-335: Pediatric Pressure Injuries Measure Description:

This measure answers the question: How often is a patient harmed due to pressure injury? The National

Pressure Ulcer Advisory Panel (NPUAP) will serve as the guide

for the defining and staging of pressure injury. The Solutions for Patient Safety (SPS) operational

definition will serve as the official guide for the reporting of all hospital acquired pressure injuries

detected during hospitalization.


NQF Number NA



Measure Parts 2


Numerator Description All Harm Numerator: Number of Mucosal, Stage 2, 3, 4, deep tissue pressure injuries (DTPI), and unstageable pressure injuries as defined below. Serious Harm Numerator: Number of Stage 3, 4, and unstageable pressure injuries as defined below.

Denominator Description Denominator for both All Harm and Serious Harm: Total number patient days.

Inclusions All patients are included who are defined as inpatient or under observation at the hospital.

Exclusions Any patient who has a PI documented upon admission to the hospital, would be excluded because this would be considered a non-facility acquired PI (unless the PI progresses to a stage 3, 4, or unstageable during their hospital stay). All Harm Excludes Stage I pressure injury: Intact skin with a localized area of non-blanch able erythema, which may appear differently in darkly pigmented skin. Presence of blanch able erythema or change sin sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Serious Harm Excludes: Stage 1, 2, Mucosal Injuries, and DTPI.




Additional Notes

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BUNDLE D4: PEDIATRIC CHRONIC DISEASE MANAGEMENT: ASTHMA

D4-139: Asthma Admission Rate (PDI14) (BAT recommendation to report for ages 5 - 18) Measure Description:

Admissions with a principal diagnosis of asthma per 100,000 population, ages 2 through 17 years.

Excludes cases with a diagnosis code for cystic fibrosis and anomalies of the respiratory system,

obstetric admissions, and transfers from other institutions.


NQF Number 0728



Measure Parts 1


Numerator Description Discharges, for patients ages 2 through 17 years, with a principal diagnosis code for asthma.

Denominator Description Population ages 2 through 17 years in metropolitan area(1)or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.






Additional Notes Admissions for ages 5 - 18

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D4-173: Medication Management for People with Asthma (75%) Measure Description:

The percentage of patients 5-64 years of age during the measurement year who were identified as

having persistent asthma and were dispensed appropriate medications that they remained on during

the treatment period. One rate is reported: the percentage of patients who remained on an asthma

controller medication for at least 75% of their treatment period.


NQF Number 1799



Measure Parts 1


Numerator Description The number of patients who achieved a PDC* of at least 75% for their asthma controller medications during the measurement year. A higher rate is better. *PDC is the proportion of days covered by at least one asthma controller medication prescription, divided by the number of days in the treatment period. The treatment period is the period of time beginning on the earliest prescription dispensing date for any asthma controller medication during the measurement year through the last day of the measurement year.

Denominator Description All patients 5–64 years of age as of December 31 of the measurement year who have persistent asthma by meeting at least one of the following criteria during both the measurement year and the year prior to the measurement year: • At least one emergency department visit with asthma as the principal diagnosis • At least one acute inpatient claim/encounter with asthma as the principal diagnosis • At least four outpatient visits or observation visits on different dates of service, with any diagnosis of asthma AND at least two asthma medication dispensing events. Visit type need not be the same for the four visits. • At least four asthma medication dispensing events


Exclusions 1) Exclude patients who had any of the following diagnoses any time during the patient’s history through the end of the measurement year (e.g., December 31): -COPD -Emphysema -Obstructive Chronic Bronchitis -Chronic Respiratory Conditions Due To Fumes/Vapors -Cystic Fibrosis

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-Acute Respiratory Failure 2) Exclude any patients who had no asthma controller medications dispensed during the measurement year.




Additional Notes Rate 1 only (75%)

CMS Alignment: Child Core Set; CMS Consensus Core Set: ACO and PCMH / Primary Care Measures;

MACRA MIPS Measure.

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D4-209: Asthma Percent of Opportunity Achieved Measure Description:

This measure is an asthma composite measure and is calculated by adding or "rolling up" the number of

times recommended care was provided over all the process measures in the given measure set and

dividing this sum by the total number of opportunities for providing this recommended care.


NQF Number NA

Measure Steward NA


Measure Parts 1

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: NA MPL: NA

Numerator Description The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) : 1.) Documentation of Action/Management Plan, 2.) Severity Assessment 3.) Controller Therapy for those who are eligible, and 4.) Documentation of spirometry assessment completed within last two years.

Denominator Description The total number of opportunities can be calculated in the following manner- For each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period.




Data Source Clinical data; Electronic health records; Administrative claims.


Additional Notes

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D4-249: Pediatric/Young Adult Asthma Emergency Department Visits Measure Description:

Percentage of patients with asthma who have greater than or equal to one visit to the emergency room

for asthma during the measurement period.


NQF Number 1381

Measure Steward Alabama Medicaid Agency


Measure Parts 1


Numerator Description Measuring percentage of people with Asthma that have an emergency room visit during a 12 month measurement period.

Denominator Description Denominator is all patients age two through age 20, diagnosed with asthma during the measurement period.


Exclusions Excludes children less than age two or greater than age twenty.




Additional Notes

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D4-375: Asthma: Pharmacologic Therapy for Persistent Asthma (rate 3) (Rate 3 only) Measure Description:

Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were

prescribed long-term control medication

Three rates are reported for this measure:

1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication

2. Patients prescribed other alternative long term control medications (non-ICS)

3. Total patients prescribed long-term control medication


NQF Number 0047

Measure Steward The American Academy of Asthma Allergy and Immunology


Measure Parts 1


Numerator Description Patients who were prescribed long-term control medication

Denominator Description All patients aged 5 years and older with a diagnosis of persistent asthma


Exclusions Denominator Exceptions: Documentation of patient reason(s) for not prescribing inhaled corticosteroids or alternative long-term control medication (eg, patient declined, other patient reason) The AAAAI follows PCPI exception methodology and PCPI distinguishes between measure exceptions and measure exclusions. Exclusions arise when patients who are included in the initial patient or eligible population for a measure do not meet the denominator criteria specific to the intervention required by the numerator. Exclusions are absolute and apply to all patients and therefore are not part of clinical judgment within a measure. For this measure, exceptions may include patient reason(s) (eg, patient declined). Although this methodology does not require the external reporting of more detailed exception data, the AAAAI recommends that physicians document the specific reasons for exception in patients’ medical records for purposes of optimal patient management and audit-readiness. In further accordance with PCPI exception methodology, the AAAAI advocates the systematic review and analysis of each physician’s exceptions data to identify practice patterns and opportunities for quality improvement.



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Additional Notes Rate 3 only

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D4-376: Asthma Quality of Life Assessment Tool Measure Description:

0


NQF Number NA

Measure Steward NA


Measure Parts 1







Data Source TBD


Additional Notes

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BUNDLE E1: IMPROVED MATERNAL CARE

E1-148: PC-01 Elective Delivery (Patients with elective vaginal deliveries or elective cesarean) Measure Description:

This measure assesses patients with elective vaginal deliveries or elective cesarean sections at >= 37 and

< 39 weeks of gestation completed. This measure is a part of a set of five nationally implemented

measures that address perinatal care (PC-02: Cesarean Section, PC-03: Antenatal Steroids, PC-04: Health

Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding)





Measure Parts 1


Numerator Description Patients with elective deliveries with ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for one or more of the following: • Medical induction of labor as defined in Appendix A, Table 11.05 available at: http://manual.jointcommission.org/releases/TJC2016A/ while not in Labor prior to the procedure • Cesarean birth as defined in Appendix A, Table 11.06 and all of the following: o not in Labor o no history of a Prior Uterine Surgery available at: http://manual.jointcommission.org/releases/TJC2016A/

Denominator Description Patients delivering newborns with >= 37 and < 39 weeks of gestation completed with ICD-10-PCS Principal or Other Procedure Codes for delivery as defined in Appendix A, Table 11.01.1 available at: http://manual.jointcommission.org/releases/TJC2016A/ and with ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for planned cesarean birth in labor as defined in Appendix A, Table 11.06.1 available at: http://manual.jointcommission.org/releases/TJC2016A/


Exclusions • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07 • Less than 8 years of age • Greater than or equal to 65 years of age • Length of Stay >120 days • Gestational Age < 37 or >= 39 weeks or UTD

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Additional Notes

CMS Alignment: CMS Consensus OB/GYN Measures;

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E1-150: PC-02 Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section) Measure Description:

This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position

delivered by cesarean birth. This measure is part of a set of five nationally implemented measures that

address perinatal care.


NQF Number 0471



Measure Parts 1


Numerator Description The outcome being measured is: Patients with cesarean births with ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for cesarean birth as defined in Appendix A, Table 11.06 available at: http://manual.jointcommission.org/releases/TJC2016A/

Denominator Description The outcome target population being measured is: Nulliparous patients delivered of a live term singleton newborn in vertex presentation ICD-10-PCS Principal or Other Diagnosis Codes for delivery as defined in Appendix A, Tables 11.01.1 available at: http://manual.jointcommission.org/releases/TJC2016A/


Exclusions • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple gestations and other presentations as defined in Appendix A, Table 11.09 • Less than 8 years of age • Greater than or equal to 65 years of age • Length of Stay >120 days • Gestational Age < 37 weeks or UTD


Data Source Paper Records


Additional Notes

CMS Alignment: Child Core Set; CMS Consensus OB/GYN Measures;

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E1-151: PC-03 Antenatal Steroids Measure Description:

This measure assesses patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving

antenatal steroids prior to delivering preterm newborns. This measure is a part of a set of five nationally

implemented measures that address perinatal care.


NQF Number 0476



Measure Parts 1


Numerator Description Patients with antenatal steroids initiated prior to delivering preterm newborns (refer to Appendix C, Table 11.0, antenatal steroid medications available at: http://manual.jointcommission.org/releases/TJC2016A/)

Denominator Description Patients delivering live preterm newborns with >=24 and <34 weeks gestation completed with ICD-10-PCS Principal or Other Procedure Codes for delivery as defined in Appendix A, Table 11.01.1 available at: http://manual.jointcommission.org/releases/TJC2016A/


Exclusions • Less than 8 years of age • Greater than or equal to 65 years of age • Length of Stay >120 days • Documented Reason for Not Initiating Antenatal Steroids • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for fetal demise as defined in Appendix A, Table 11.09.1 available at: http://manual.jointcommission.org • Gestational Age < 24 or >= 34 weeks or UTD




Additional Notes

CMS Alignment: Adult Core Set; CMS Consensus OB/GYN Measures;

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E1-193: Contraceptive Care – Postpartum Women Ages 15–44 (CCP-AD)* Measure Description:

Among women ages 15 through 44 who had a live birth, the percentage that is provided:

1) A most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately

(i.e., injectables, oral pills, patch, ring, or diaphragm) effective method of contraception within 3 and 60

days of delivery.

2) A long-acting reversible method of contraception (LARC) within 3 and 60 days of delivery.

Two time periods are proposed (i.e., within 3 and within 60 days of delivery) because each reflects

important clinical recommendations from the U.S. Centers for Disease Control and Prevention (CDC) and

the American College of Obstetricians and Gynecologists (ACOG). The 60-day period reflects ACOG

recommendations that women should receive contraceptive care at the 6-week postpartum visit. The 3-

day period reflects CDC and ACOG recommendations that the immediate postpartum period (i.e., at

delivery, while the woman is in the hospital) is a safe time to provide contraception, which may offer

greater convenience to the client and avoid missed opportunities to provide contraceptive care.


NQF Number 2902

Measure Steward US Office of Population Affairs


Measure Parts 2


Numerator Description Primary measure: Women ages 15 through 44 who had a live birth and were provided a most (sterilization, intrauterine device, implant) or moderately (pill, patch, ring, injectable, diaphragm) effective method of contraception within 3 and 60 days of delivery. Sub-measure: Women ages 15 through 44 who had a live birth and were provided a long-acting reversible method of contraception (LARC) within 3 and 60 days of delivery.

Denominator Description Women ages 15 through 44 who had a live birth in a 12-month measurement year.


Exclusions The following categories are excluded from the denominator: (1) deliveries that did not end in a live birth (i.e., miscarriage, ectopic, stillbirth or induced abortion); and (2) deliveries that occurred during the last two months of the measurement year.

DSRIP Specified Setting OB



Additional Notes

CMS Alignment: Child Core Set; Adult Core Set;

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E1-232: Timeliness of Prenatal/Postnatal Care Measure Description:

The percentage of deliveries of live births between November 6 of the year prior to the measurement

year and November 5 of the measurement year. For these women, the measure assesses the following

facets of prenatal and postpartum care:

Rate 1: Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a

member of the organization in the first trimester or within 42 days of enrollment in the organization.

Rate 2: Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and

56 days after delivery.


NQF Number 1517



Measure Parts 2

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: Timeliness of Prenatal Care: 0.91 Postpartum Care: 0.7361 MPL: Timeliness of Prenatal Care: 0.7421 Postpartum Care: 0.5547

Numerator Description This measure assesses whether pregnant women had timely prenatal and postpartum care visits. It has two rates, one assessing the timeliness of prenatal visits, and one assessing the timeliness of postpartum visits. Rate 1: Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. Rate 2: Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

Denominator Description The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year.


Exclusions Non-live births




Additional Notes Rate 1 only, HHSC is dicussiong reporting rate for Medicaid only with possible alignment with MCOs

Proposed 2018 MCO P4Q Measure

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E1-235: Post-Partum Follow-Up and Care Coordination (PQRS #336) Measure Description:

Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for

post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education,

post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and

family and contraceptive planning


NQF Number NA

Measure Steward CMS


Measure Parts 1


Numerator Description Patients receiving the following at a post-partum visit: - Breast feeding evaluation and education, including patient-reported breast feeding - Post-partum depression screening - Post-partum glucose screening for gestational diabetes patients and - Family and contraceptive planning Definitions: Breast Feeding Evaluation and Education – Patients who were evaluated for breast feeding before or at 8 weeks post-partum. Post-Partum Depression Screening – Patients who were screened for post-partum depression before or at 8 weeks post-partum. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool (e.g., PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS). Post-Partum Glucose Screening for Gestational Diabetes – Patients who were diagnosed with gestational diabetes during pregnancy who were screened with a glucose screen before or at 8 weeks post-partum. Family and Contraceptive Planning – Patients who were provided family and contraceptive planning and education (including contraception, if necessary) before or at 8 weeks post-partum. Numerator Instruction: To satisfactorily meet the numerator ALL components (breast feeding evaluation and education, post-partum depression screening, family and contraceptive planning and post-partum glucose screening for patients with gestational diabetes) must be performed.

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Denominator Description All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth

Inclusions Denominator: All patients, regardless of age AND Patient encounter during reporting period (CPT): 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622 AND Post-partum Care Visit before or at 8 weeks post-delivery Numerator: Performance Met: Post-partum screenings, evaluations and education performed (G9357)

Exclusions Numerator: Performance Not Met: Post-partum screenings, evaluations and education not performed (G9358)




Additional Notes


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E1-300: Behavioral Health Risk Assessment (for Pregnant Women) (BHRA-CH) Measure Description:

Percentage of women, regardless of age, who gave birth during a 12-month period seen at least once for

prenatal care who received a behavioral health screening risk assessment that includes the following

screenings at the first prenatal visit: depression screening, alcohol use screening, tobacco use screening,

drug use screening (illicit and prescription, over the counter), and intimate partner violence screening.


NQF Number NA


Link to Measure Citation https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html

Measure Parts 1


Numerator Description Patients who received the following behavioral health screening risk assessments at the first prenatal visit. Depression screening • Patients who were screened for depression at the first visit. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer-administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool [e.g., PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS)]. Alcohol use screening • Patients who were screened for any alcohol use at the first visit Tobacco use screening • Patients who were screened for tobacco use at the first visit Drug use (illicit and prescription, over the counter) screening • Patients who were screened for any drug use at the first visit Intimate partner violence screening • Patients who were screened for intimate partner violence/abuse at the first visit. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Intimate partner violence screening may include a self-reported validated depression screening tool (e.g., Hurt, Insult, Threaten, and Scream [HITS], Woman Abuse Screening Tool [WAST], Partner Violence Screen [PVS], Abuse Assessment Screen [AAS]). To satisfactorily meet the numerator, ALL screening components must be performed.

Denominator Description All patients, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care.



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DSRIP Specified Setting Primary Care, Outpatient Specialty Care, OB, Hospital

Data Source TBD


Additional Notes


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E1-378: Appropriate Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – Cesarean section. Measure Description:

Percentage of patients undergoing cesarean section who receive appropriate prophylactic antibiotics

within 60 minutes of the start of the cesarean delivery, unless the patient is already receiving

appropriate antibiotics


NQF Number 0472

Measure Steward Massachusetts General Hospital/Partners Health Care System


Measure Parts 1


Numerator Description Percentage of women who receive recommended antibiotics within one hour before the start of cesarean section. This requires that (a) the antibiotic selection is consistent with current evidence and practice guidelines, and (b) that the antibiotics are given within an hour before delivery. If the patient is already receiving appropriate antibiotics, for example for chorioamnionitis, additonal dosing is not necessary.

Denominator Description All patients undergoing cesarean section without evidence of prior infection or already receiving prophylactic antibiotics for other reasons. Patients with significant allergies to penicillin and/or cephalosporins AND allegies to gentamicin and/or clindamycin are also excluded.


Exclusions Women with evidence of prior infection or already receiving prophylactic antibiotics for other reasons; or with significant allergies to penicillin and/or cephalosporins AND allegies to gentamicin and/or clindamycin. We do not exclude patients having emergency cesarean deliveries. We recognize that while in the case of most urgent and emergent cesarean deliveries administering timely antibiotic prophylaxis will be possible, very rarely clinical circumstances may not permit administration of antibiotic prophylaxis before skin incisions. Specifying these unusual circumstances, especially from readily abstracted medical record data, is not possible/feasible. Allowing a self-defined exclusion risks inappropriate definition. Instead we recognize that ideal performance on this measure may not be 100% given the small number of unusual emergencies and/or other circumstances. Providers/facilities should however target a 100% goal by, among other efforts, considering how antibiotic prophylaxis will be appropriately delivered even in the case of emergencies


Data Source Claims (Only), Electronic Health Record (Only), Other, Paper Records


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Additional Notes

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BUNDLE F1: IMPROVED ACCESS TO ADULT DENTAL CARE

F1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention Measure Description:




NQF Number 0028



Measure Parts 1












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F1-226: Chronic Disease Patients Accessing Dental Services Measure Description:

Percentage of patients with chronic disease conditions accessing dental services following referral by

their medical provider


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Number of chronic disease patients who access dental services as the result of a referral

Denominator Description Total number of referrals for dental services for chronic disease patients by medical providers



DSRIP Specified Setting Dental Clinic

Data Source Administrative/Clinical data sources; Supplemental data sources


Additional Notes

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F1-227: Dental Caries: Adults Measure Description:

Percentage of adults aged 18 or more years with untreated dental decay


NQF Number NA

Measure Steward Healthy People 2020


Measure Parts 1


Numerator Description Number of adults aged 18 years or more with coronal caries that has not been restored in at least one permanent tooth

Denominator Description Number of adults aged 18 or more years with at least one permanent tooth present and valid coronal caries codes for at least one permanent tooth






Additional Notes Measure title changed to Dental Caries: Adults

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BUNDLE F2: PREVENTIVE PEDIATRIC DENTAL

F2-224: Dental Sealant: Children Measure Description:

Increase the proportion of children aged 6 to 9 years who have received dental sealants on one or more

of their permanent first molar teeth


NQF Number NA


Link to Measure Citation https://www.healthypeople.gov/node/5001/data_details

Measure Parts 1


Numerator Description Number of children aged 6 to 9 with a clinical confirmation of dental sealants applied to one or more first permanent molars

Denominator Description Number of children aged 6 to 9 with at least one permanent first molar present and valid sealant codes for at least one permanent first molar




Data Source TBD



PREVIEW

https://www.healthypeople.gov/node/5001/data_details


F2-225: Dental Caries: Children Measure Description:

Percentage of children with untreated dental caries


NQF Number NA



Measure Parts 1


Numerator Description Number of children with untreated dental caries

Denominator Description Total number of children that have seen a dental provider within the measurement period




Data Source Administrative/Clinical data sources; supplemental data sources


Additional Notes

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F2-229: Oral Evaluation: Children - Modified Denominator Measure Description:

Percentage of enrolled children under age 21 years who received a comprehensive or periodic oral

evaluation within the reporting year.



Measure Steward American Dental Association


Measure Parts 2


Numerator Description Unduplicated number of enrolled children under age 21 years who received a comprehensive or periodic oral evaluation as a dental service

Denominator Description Unduplicated number of all children under age 21 with at least one (1) visit in the prior or current year.


Exclusions Medicaid/CHIP programs should exclude those individuals who do not qualify for dental benefits. The exclusion criteria should be reported along with the number and percentage of members excluded There are no other exclusions.





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F2-231: Preventive Services for Children at Elevated Caries Risk - Modified Denominator Measure Description:

Percentage of enrolled children who are at “elevated” risk (i.e., “moderate” or “high”) who received a

topical fluoride application and/or sealants within the reporting year


NQF Number NA


Link to Measure Citation http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ DQA_2017_Dental_Services_Preventive_Services.pdf?la=en

Measure Parts 2


Numerator Description Unduplicated number of children at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants as a dental service

Denominator Description Unduplicated number of enrolled children at “elevated” risk (i.e., “moderate” or “high”)




Data Source Administrative enrollment and claims data



PREVIEW


BUNDLE G1: PALLIATIVE CARE

G1-276: Hospice and Palliative Care – Pain assessment Measure Description:

Percentage of hospice or palliative care patients who screened positive for pain and who received a

clinical assessment of pain within 24 hours of screening.


NQF Number 1637

Measure Steward University of North Carolina-Chapel Hill


Measure Parts 1


Numerator Description Patients who received a comprehensive clinical assessment to determine the severity, etiology and impact of their pain within 24 hours of screening positive for pain.

Denominator Description Patients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting who report pain when pain screening is done on the admission evaluation / initial encounter.


Exclusions Patients with length of stay < 1 day in palliative care. Patients who screen negative for pain are excluded from the denominator.

DSRIP Specified Setting Hospice, Hospital




PREVIEW



G1-277: Hospice and Palliative Care – Treatment Preferences Measure Description:

Percentage of patients with chart documentation of preferences for life sustaining treatments.


NQF Number 1641



Measure Parts 1


Numerator Description Patients whose medical record includes documentation of life sustaining preferences

Denominator Description Seriously ill patients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting.


Exclusions Patients with length of stay < 1 day in hospice or palliative care




Additional Notes

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G1-278: Beliefs and Values - Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss. Measure Description:

This measure reflects the percentage of hospice patients with documentation of a discussion of

spiritual/religious concerns or documentation that the patient/caregiver/family did not want to discuss.


NQF Number 1647



Measure Parts 1


Numerator Description Patients whose medical record includes documentation that the patient and/or caregiver was asked about spiritual/existential concerns within 5 days of the admission date.

Denominator Description Seriously ill patients 18 years of age or older enrolled in hospice.


Exclusions Testing has only been done with the adult population; thus patients younger than 18 are excluded.

DSRIP Specified Setting Hospice




PREVIEW



G1-285: Advance Care Plan Measure Description:






NQF Number 0326



Measure Parts 1









Additional Notes


PREVIEW



G1-361: Patients Treated with an Opioid who are Given a Bowel Regimen Measure Description:

Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or

documentation of why this was not needed


NQF Number 1617

Measure Steward RAND Corporation/UCLA


Measure Parts 1


Numerator Description Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed

Denominator Description Vulnerable adults who are given a prescription for an opioid


Exclusions Non-hospice outpatients who are already taking an opioid at the time of the study period opioid prescription




Additional Notes

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G1-362: Hospice and Palliative Care -- Dyspnea Treatment Measure Description:

Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of

screening.


NQF Number 1638



Measure Parts 1


Numerator Description Patients who screened positive for dyspnea who received treatment within 24 hours of screening.

Denominator Description Patients enrolled in hospice OR patients receiving hospital-based palliative care for 1 or more days.


Exclusions Patients with length of stay < 1 day in palliative care, patients who were not screened for dyspnea, and/or patients with a negative screening.




Additional Notes

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G1-363: Hospice and Palliative Care -- Dyspnea Screening Measure Description:

Percentage of hospice or palliative care patients who were screened for dyspnea during the hospice

admission evaluation / palliative care initial encounter.


NQF Number 1639



Measure Parts 1


Numerator Description Patients who are screened for the presence or absence of dyspnea and its severity during the hospice admission evaluation / initial encounter for palliative care.

Denominator Description Patients enrolled in hospice OR patients receiving hospital-based palliative care for 1 or more days.


Exclusions Patients with length of stay < 1 day in palliative care.




Additional Notes

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G1-364: Patients with Advanced Cancer Screened for Pain at Outpatient Visits Measure Description:

Adult patients with advanced cancer who are screened for pain with a standardized quantitative tool at

each outpatient visit


NQF Number 1628

Measure Steward RAND Corporation


Measure Parts 1


Numerator Description Outpatient visits from the denominator in which the patient was screened for pain (and if present, severity noted) with a quantitative standardized tool

Denominator Description Adult patients with advanced cancer who have at least 1 primary care or cancer-related/specialty outpatient visit


Exclusions None (other than those patients noted in 2a1.7. who did not survive at least 30 days after cancer diagnosis)


Data Source Electronic Health Record (Only), Paper Records, Registry


Additional Notes

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BUNDLE H1: INTEGRATION OF BEHAVIORAL HEALTH IN A PRIMARY CARE

SETTING

H1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention Measure Description:




NQF Number 0028



Measure Parts 1












DRAFT

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H1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) Measure Description:

Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate

standardized tool AND follow-up plan documented


NQF Number 0418

Measure Steward CMS


Measure Parts 1


Numerator Description Patient’s screening for clinical depression using an age appropriate standardized tool AND follow-up plan is documented The standardized screening tools help predict a likelihood of someone developing or having a particular disease. The screening tools suggested in this measure screen for possible depression. Questions within the suggested standardized screening tools may vary but the result of using a standardized screening tool is to determine if the patient screens positive or negative for depression. If the patient has a positive screen for depression using a standardized screening tool, the provider must have a follow-up plan as defined within the measure. If the patient has a negative screen for depression, no follow-up plan is required.



Exclusions Not Eligible/Not Appropriate – A patient is not eligible if one or more of the following conditions exist: • Patient refuses to participate • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status • Situations where the patient’s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases • Patient was referred with a diagnosis of depression • Patient has been participating in on-going treatment with screening of clinical depression in a preceding reporting period • Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools

DSRIP Specified Setting Primary Care, Specialty Care



DRAFT

PREVIEW



Additional Notes BAT recommendation to stratify as two rates, ages 18+ and 12 - 17 and to expand to screening for general behavioral health concerns including anxiety

CMS Alignment: Adult Core Set; MACRA MIPS Measure;CCBHC Measure.

DRAFT

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H1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD) Measure Description:

The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication

who had at least three follow-up care visits within a 10-month period, one of which is within 30 days of

when the first ADHD medication was dispensed.

An Initiation Phase Rate and Continuation and Maintenance Phase Rate are reported.


NQF Number 0108



Measure Parts 2


Numerator Description This measure assesses the receipt of follow-up visits for children prescribed ADHD medication. Two rates are reported. 1. INITIATION PHASE: The percentage of children between 6 and 12 years of age who were newly prescribed ADHD medication who had one follow-up visit with a prescribing practitioner within 30 days. 2. CONTINUATION AND MAINTENANCE PHASE: The percentage of children between 6 and 12 years of age newly prescribed ADHD medication and remained on the medication for at least 210 days, who had, in addition to the visit in the Initiative Phase, at least two follow-up visits with a practitioner in the 9 months subsequent to the Initiation Phase.

Denominator Description Children 6-12 years of age newly prescribed ADHD medication.


Exclusions Children with a diagnosis of narcolepsy

DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Behavioral Health Outpatient



Additional Notes


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H1-286: Depression Remission at Six Months Measure Description:

Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who

demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both

patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for

treatment. This measure additionally promotes ongoing contact between the patient and provider as

patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the

denominator.


NQF Number 0711

Measure Steward MN Community Measurement


Measure Parts 1


Numerator Description Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five.

Denominator Description Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine.


Exclusions Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis (in any position) of bipolar or personality disorder are excluded.

DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Behavioral Health: Outpatient





DRAFT

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H1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Measure Description:

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a

systematic screening method at least once within the last 24 months AND who received brief counseling

if identified as an unhealthy alcohol user


NQF Number 2152



Measure Parts 1


Numerator Description Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user



Exclusions Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy, other medical reasons)

DSRIP Specified Setting Behavioral Health: Outpatient, Primary Care, Outpatient Specialty Care




MACRA MIPS Measure; CCBHC Measure.

DRAFT

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BUNDLE H2: BEHAVIORAL HEALTH AND APPROPRIATE UTILIZATION

H2-160: Follow-Up After Hospitalization for Mental Illness Measure Description:

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment

of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter

or partial hospitalization with a mental health practitioner. Two rates are reported:

- The percentage of discharges for which the patient received follow-up within 30 days of discharge

- The percentage of discharges for which the patient received follow-up within 7 days of discharge.


NQF Number 0576



Measure Parts 2

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: 30 Days: 0.7852 7 Days: 0.6423 MPL: 30 Days: 0.5408 7 Days: 0.342

Numerator Description 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. Include outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the date of discharge. 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. Include outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the date of discharge.

Denominator Description Patients 6 years and older as of the date of discharge who were discharged from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year (e.g., January 1 to December 1).


Exclusions Exclude both the initial discharge and the readmission/direct transfer discharge if the readmission/direct transfer discharge occurs after the first 11 months of the measurement year (e.g., after December 1). Exclude discharges followed by readmission or direct transfer to a nonacute facility within the 30-day follow-up period, regardless of principal diagnosis for the readmission. Exclude discharges followed by readmission or direct transfer to an acute facility within the 30-day follow-up period if the principal diagnosis was for non-mental health (any principal diagnosis code other than those included in the Mental Health Diagnosis Value Set).

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These discharges are excluded from the measure because rehospitalization or transfer may prevent an outpatient follow-up visit from taking place.

DSRIP Specified Setting Behavioral Health: Inpatient, Behavioral Health: Outpatient, Hospital



Additional Notes

CMS Alignment: Child Core Set; Adult Core Set; MACRA MIPS Measure.

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H2-216: Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate Measure Description:

Risk adjusted rate of hospital admissions for Behavioral Health /Substance Abuse (BH/SA) that had at

least one readmission for any reason within 30 days of discharge for patients 18 years of age and older.





measurement year.


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Observed (Actual) rate of readmissions within 30 days following an Index Admission for BH/SA during the measurement year. The Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk BH/SA admissions during the measurement period.

Denominator Description Expected (risk-adjusted) rate of readmissions for BH/SA during the measurement year. The Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.




Data Source Administrative Claims, Electronic Health Records


Additional Notes

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H2-259: Assignment of Primary Care Physician to Individuals with Schizophrenia Measure Description:

The percentage of individuals with a primary diagnosis of schizophrenia that have been assigned a

primary care physician.


NQF Number NA

Measure Steward Center for Quality Assessment and Improvement in Mental Health (CQAIMH)

Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=UTAH0004D&POP=0

Measure Parts 1


Numerator Description The number of individuals in the denominator who were assigned a primary care physician.

Denominator Description Enrollees who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.



DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Behavioral Health Outpatient, Hospital

Data Source Administrative Data; Medical Record



PREVIEW

http://www.cqaimh.org/Report.asp?Code=UTAH0004D&POP=0


H2-265: Housing Assessment for Individuals with Schizophrenia Measure Description:

The percentage of individuals with Schizophrenia whose housing quality was assessed


NQF Number NA



Measure Parts 1


Numerator Description The number of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation.








PREVIEW



H2-266: Independent Living Skills Assessment for Individuals with Schizophrenia Measure Description:

The percentage of patients who received an assessment of independent living skills


NQF Number NA



Measure Parts 1


Numerator Description Patients in the denominator who received an assessment of independent living skills.

Denominator Description Patients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.






Additional Notes

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H2-305: Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment (SRA-CH) Measure Description:

Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major

depressive disorder with an assessment for suicide risk


NQF Number 1365



Measure Parts 1


Numerator Description Patient visits with an assessment for suicide risk

Denominator Description All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder



DSRIP Specified Setting Behavioral Health: Outpatient, Primary Care, Outpatient Specialty Care, Hospital

Data Source Electronic Health Record (Only): Electronic Health Record


Additional Notes

CMS Alignment: Child Core Set; MACRA MIPS Measure; CCBHC Measure. DRAFT

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H2-316: Alcohol Screening and Follow-up for People with Serious Mental Illness Measure Description:

The percentage of patients 18 years and older with a serious mental illness, who were screened for

unhealthy alcohol use and received brief counseling or other follow-up care if identified as an unhealthy

alcohol user.


NQF Number 2599



Measure Parts 1


Numerator Description Patients 18 years and older who are screened for unhealthy alcohol use during the last 3 months of the year prior to the measurement year through the first 9 months of the measurement year and received two events of counseling if identified as an unhealthy alcohol user.

Denominator Description All patients 18 years of age or older as of December 31 of the measurement year with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year.


Exclusions Active diagnosis of alcohol abuse or dependence during the first nine months of the year prior to the measurement year (see Alcohol Disorders Value Set).




Additional Notes

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H2-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure) Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)

with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode

was identified


NQF Number 0104



Measure Parts 1


Numerator Description Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Denominator Description All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)






Additional Notes

MACRA MIPS Measure; CCBHC Measure. DRAFT

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H2-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates) Measure Description:

Rate of ED utilization for substance use conditions or complications


NQF Number NA

Measure Steward NA


Measure Parts 2


Numerator Description Total number of ED Visits with a primary or secondary diagnosis of (excluding tobacco) substance abuse for any individual 18 years and older during the measurement period





Data Source TBD


Additional Notes Reported as two rates DRAFT

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BUNDLE H3: CHRONIC NON-MALIGNANT PAIN MANAGEMENT

H3-144: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) for individuals with a diagnosis of chronic pain Measure Description:




NQF Number 0418

Measure Steward CMS


Measure Parts 1





Exclusions Not Eligible/Not Appropriate – A patient is not eligible if one or more of the following conditions exist: • Patient refuses to participate • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status • Situations where the patient’s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases • Patient was referred with a diagnosis of depression • Patient has been participating in on-going treatment with screening of clinical depression in a preceding reporting period • Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where

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depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools

DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Hospital, Inpatient Rehabilitation Facility, Other



Additional Notes Denominator subset of chronic pain

CMS Alignment: Adult Core Set; MACRA MIPS Measure.

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H3-197: Use of Opioids at High Dosage - modified denominator Measure Description:

The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a

daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer.



Measure Steward Pharmacy Quality Alliance


Measure Parts 1


Numerator Description Any member in the denominator with opioid prescription claims where the MED is greater than 120mg for 90 consecutive days or longer

Denominator Description Any member with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is greater than or equal to 15.


Exclusions Any member with a diagnosis for Cancer or a Prescription Drug Hierarchical Condition Category (RxHCC) 8, 9, 10, or 11 for Payment Year 2015; or RxHCC 15, 16, 17, 18, or 19 for Payment Year 2016 (see list in S.11 and S.2b); or a hospice indicator (Medicare Part D) from the enrollment database.

DSRIP Specified Setting Other, Pharmacy



Additional Notes

CMS Alignment: Adult Core Set; DRAFT

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H3-257: Care Planning for Dual Diagnosis Measure Description:

Percentage of patients with dual diagnosis undergoing case management services who have a

documented plan to address both conditions.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=TENN0017D&POP=5

Measure Parts 1


Numerator Description Those individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions.

Denominator Description The number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder during a six-month period.







PREVIEW

http://www.cqaimh.org/Report.asp?Code=TENN0017D&POP=5


H3-287: Documentation of Current Medications in the Medical Record Measure Description:







NQF Number 0419

Measure Steward CMS


Measure Parts 1









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Additional Notes


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H3-288: Pain Assessment and Follow-up Measure Description:

Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using

a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present


NQF Number 0420

Measure Steward CMS


Measure Parts 1


Numerator Description Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.

Denominator Description All visits for patients aged 18 years and older


Exclusions Not Eligible – A patient is not eligible if one or more of the following reason(s) is documented: Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

DSRIP Specified Setting Behavioral Health: Outpatient, Primary Care, Outpatient Specialty Care, Outpatient Rehabilitation

Data Source Claims (Only), Paper Records


Additional Notes

MACRA MIPS Measure.

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BUNDLE H4: INTEGRATED CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS

H4-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD) Measure Description:

The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were

dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.


NQF Number 1932



Measure Parts 1


Numerator Description Among patients 18-64 years old with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year.

Denominator Description Patients ages 18 to 64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication.


Exclusions Exclude members who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients with diabetes during the measurement year or the year prior to the measurement year. Exclude patients who had no antipsychotic medications dispensed during the measurement year.


Data Source Claims (Only), Electronic Health Record (Only), Laboratory, Pharmacy


Additional Notes

CMS Alignment: Adult Core Set; Proposed 2018 MCO P4Q Measure.

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H4-258: Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC) Measure Description:

The percentage of patients 18 – 64 years of age with schizophrenia and cardiovascular disease, who had

an LDL-C test during the measurement year.


NQF Number 1933



Measure Parts 1


Numerator Description One or more LDL-C tests performed during the measurement year.

Denominator Description Patients 18-64 years of age as of the end of the measurement year with a diagnosis of schizophrenia and cardiovascular disease.


Exclusions Not applicable.


Data Source Claims (Only), Electronic Health Record (Only), Laboratory



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H4-260: Annual Physical Exam for Persons with Mental Illness Measure Description:

The percentage of individuals receiving services for a primary psychiatric disorder whose medical

records document receipt of a physical exam during the measurement year.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=MHSI0002D&POP=0

Measure Parts 1


Numerator Description Individuals from the denominator whose medical record documents receipt of a physical examination within the specified 12-month period.

Denominator Description The total number of individuals receiving services for a primary psychiatric disorder during a specified 12- month reporting period.






Additional Notes

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http://www.cqaimh.org/Report.asp?Code=MHSI0002D&POP=0


BUNDLE I1: SPECIALTY CARE

I1-385: Assessment of Funcitonal Status or QoL (Modified from NQF# 0260/2624) Measure Description:

Percent of eligible patients who completed a health-related quality of life assessment or functional

assessment using a standardized tool at least once during the measurement period.


NQF Number NA

Measure Steward NA

Link to Measure Citation NA

Measure Parts 1


Numerator Description Number of eligible patients who completed a health-related quality of life assessment or functional assessment using a standardized tool at least once during the measurement period.

Denominator Description Number of eligible individuals receiving specialty care services during the measurement period



DSRIP Specified Setting Specialty Care

Data Source TBD



PREVIEW


I1-386: Improvement in Functional Status or QoL (Modified from PQRS #435) Measure Description:

Percent of patients who had a follow up health-related quality of life or functional status assessed

during the measurement period whose score stayed the same or improved.


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Patients whose score stayed the same or improved.

Denominator Description Patients who had a follow up health-related quality of life or functional status assessed during the measurement period




Data Source TBD


Additional Notes

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BUNDLE J1: HOSPITAL SAFETY

J1-218: Central line-associated bloodstream infections (CLABSI) rates Measure Description:

Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream

infections (CLABSI) will be calculated among patients in bedded inpatient care locations.

This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals,

oncology hospitals, and behavioral health hospitals.


NQF Number 0139

Measure Steward CDC


Measure Parts 1


Numerator Description Total number of observed healthcare-associated CLABSI among patients in bedded inpatient care locations.

Denominator Description Total number of central line days for each location under surveillance for CLABSI during the data period.


Exclusions 1. Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are excluded as CLs. 2. Extracoporeal membrane oxygenation lines, femoral arterial catheters, intraaortic balloon pump devices, and hemodialysis reliable outflow catheters (HeRO) are excluded as CLs. 3. Peripheral intravenous lines are excluded as CLs.

DSRIP Specified Setting Behavioral Health: Inpatient, Hospice, Hospital, Inpatient Rehabilitation Facility, Long Term Acute Care, Other

Data Source Electronic Health Record (Only), Laboratory, Other, Paper Records


Additional Notes

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J1-219: Catheter-associated Urinary Tract Infections (CAUTI) rates Measure Description:

Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections

(UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III

neonatal intensive care units (NICU).

This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals,

oncology hospitals, and behavior health hospitals.


NQF Number 0138

Measure Steward CDC


Measure Parts 1


Numerator Description Total number of observed healthcare-associated CAUTI among patients in bedded inpatient care locations (excluding patients in Level II or III neonatal ICUs).

Denominator Description Total number of indwelling urinary catheter days for each location under surveillance for CAUTI during the data period.


Exclusions The following are not considered indwelling catheters by NHSN definitions: 1.Suprapubic catheters 2.Condom catheters 3.“In and out” catheterizations 4. Nephrostomy tubes Note, that if a patient has either a nephrostomy tube or a suprapubic catheter and also has an indwelling urinary catheter, the indwelling urinary catheter will be included in the CAUTI surveillance.

DSRIP Specified Setting Behavioral Health: Inpatient, Hospice, Hospital, Long Term Acute Care, Nursing Home / SNF, Other



Additional Notes

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J1-220: Surgical site infections (SSI) rates Measure Description:

Percentage of surgical site infections occurring within thirty days after the operative procedure if no

implant is left in place or with one year if an implant is in place in patients who had an NHSN operative

procedure performed during a specified time period and the infection appears to be related to the

operative procedure.


NQF Number 0299

Measure Steward CDC


Measure Parts 1


Numerator Description Number of surgical site infections occurring within thirty days after the operative procedure if no implant is left in place or with one year if an implant is in place in patients who had an NHSN operative procedure performed during a specified time period and the infection appears to be related to the operative procedure. Infections are identified on original admission or upon readmission to the facility of original operative procedure within the relevant time frame (30 days for no implants; within 1 year for implants). Two types of CDC-defined SSIs are included: (1) A deep incisional SSI must meet the following criteria: • Infection occurs within 30 days after the operative procedure if no implant is left or within one year if implant is in place and the infection appears to be related to the operative procedure and • involves deep soft tissues (e.g., fascial and muscle layers) of the incision and • patient has at least one of the following: a) purulent drainage from the deep incision but not from the organ/space component of the surgical site b) a deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured when the patient has at least one of the following signs or symptoms: fever (>38°C), or localized pain or tenderness. A culture-negative finding does not meet this criterion. c) an abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination d) diagnosis of a deep incisional SSI by a surgeon or attending physician. Note: There are two specific types of deep incisional SSIs:

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1) Deep Incisional Primary (DIP) – a deep incisional SSI that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CABG) 2) Deep Incisional Secondary (DIS) - a deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site [leg] incision for CBGB) (2) An organ/space SSI must meet the following critieria: • Infection occurs within 30 days after the operative procedure if no implant is left or within one year if implant is in place and the infection appears to be related to the operative procedure and • infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and • patient has at least one of the following: a). purulent drainage from a drain that is placed through a stab wound into the organ/space b). organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space c). an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination d) diagnosis of an organ/space SSI by a surgeon or attending physician. Specific sites of an organ/space SSI may be identified

Denominator Description Number of NHSN operative procedures performed during a specified time period stratified by: • Type of NHSN operative procedure and • NNIS SSI risk index: Every patient having the selected procedure is assigned one (1) risk point for each of the following three factors: o Surgical wound classification = clean contaminated or dirty o American Society of Anesthesiologists (ASA) preoperative severity of illness score = 3, 4, or 5 o Duration of operation >t hours, where t varies by type of NHSN operative procedure and is the approximate 75th percentile of the duration of the procedure rounded to the nearest whole number of hours. Note: For operative procedures performed using lapyroscopes and endoscopes the use of a lapyroscope is an additional factor that modifies the risk index.


Exclusions Exclude Procedures Not Included Under The Definition Of NHSN Operative Procedure And Excludes Superficial SSI.

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Additional Notes

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J1-221: Patient Fall Rate Measure Description:

All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar

quarter. Reported as Total Falls per 1,000 Patient Days.

(Total number of falls / Patient days) X 1000


NQF Number 0141

Measure Steward American Nurses Association


Measure Parts 2


Numerator Description Total number of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the calendar month X 1000. Target population is adult acute care inpatient and adult rehabilitation patients. Eligible unit types include adult critical care, adult step-down, adult medical, adult surgical, adult medical-surgical combined, critical access, adult rehabilitation in-patient.

Denominator Description Denominator Statement: Patient days by hospital unit during the calendar month times 1000.

Inclusions Denominator Inclusions: •Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on eligible inpatient units for all or part of a day on the following unit types: •Adult critical care, step-down, medical, surgical, medical-surgical combined, critical access, and adult rehabilitation units. •Patients of any age on an eligible reporting unit are included in the patient day count.

Exclusions Excluded Populations: Other unit types (e.g., pediatric, psychiatric, obstetrical, etc.)




Additional Notes

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J1-222: Severe Sepsis and Septic Shock: Management Bundle Measure Description:

This measure will focus on patients aged 18 years and older who present with symptoms of severe

sepsis or septic shock. These patients will be eligible for the 3 hour (severe sepsis) and/or 6 hour (septic

shock) early management bundle.


NQF Number 0500

Measure Steward Henry Ford Hospital


Measure Parts 1


Numerator Description If: A. measure lactate level B. obtain blood cultures prior to antibiotics C. administer broad spectrum antibiotics D. administer 30 ml/kg crystalloid for hypotension or lactate = 4 mmol/L E. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean areterial pressure = 65) F. in the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was = 4 mmol/L, re-assess volume status and tissue perfusion and document findings.* * To meet the requirements, a focused exam† by a licensed independent practitioner (LIP) or any 2 other items are required: • Measure CVP • Measure ScvO2 • Bedside cardiovascular ultrasound • Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge • Focused exam† including vital signs, cardiopulmonary, capillary refill, pulse and skin findings. G. remeasure lactate if initial lactate is elevated represent processes of care: Numerator statement: Patients from the denominator who received all the following: A, B, and C within 3 hours of time of presentation† AND IF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received D and E and F and G within 6 hours of time of presentation. † ”time of presentation” is defined as the time of triage in the Emergency Department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review.

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* “hypotension” is defined as systolic blood pressure (SBP) <90 mm Hg or mean arterial pressure (MAP) <70 mm Hg or a SBP decrease >40 mm Hg or <2 SD below normal for age or known baseline. Denominator Statement: Number of patients presenting with severe sepsis or septic shock.

Denominator Description Number of patients presenting with severe sepsis or septic shock.


Exclusions A) Patients with advanced directives for comfort care are excluded. B) Clinical conditions that preclude total measure completion should be excluded (e.g. mortality within the first 6 hours of presentation as defined above in 2a1.1). C) Patients for whom a central line is clinically contraindicated (e.g. coagulopathy that cannot be corrected, inadequate internal jugular or subclavian central venous access due to repeated cannulations). D) Patients for whom a central line was attempted but could not be successfully inserted. E) Patient or surrogate decision maker declined or is unwilling to consent to such therapies or central line placement. F) Patients transferred to an acute care facility from another acute care facility.


Data Source Electronic Health Record (Only), Other, Paper Records, Registry


Additional Notes

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J1-372: National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure Measure Description:

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM)of hospital-onset unique blood

source MRSA Laboratory-identified events (LabID events) among all inpatients in the facility


NQF Number 1716

Measure Steward Centers for Disease Control and Prevention


Measure Parts 1


Numerator Description Total number of observed hospital-onset unique blood source MRSA LabID events among all inpatients in the facility

Denominator Description Total number of expected hospital-onset unique blood source MRSA LabID events, calculated using the facility´s number of inpatient days, bedsize, affiliation with medical school, and community-onset MRSA bloodstream infection admission prevalence rate.


Exclusions Data from patients who are not assigned to an inpatient bed are excluded from the denominator counts. These include outpatient clinic and emergency department visits.




Additional Notes

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BUNDLE K1: RURAL PREVENTIVE CARE

K1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention Measure Description:




NQF Number 0028



Measure Parts 1












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K1-112: Comprehensive Diabetes Care: Foot Exam Measure Description:

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot

exam (visual inspection and sensory exam with mono filament and a pulse exam) during the

measurement year.


NQF Number 0056



Measure Parts 1


Numerator Description Patients who received a foot exam (visual inspection and sensory exam with monofilament and pulse exam) during the measurement year.







Additional Notes


Measure.

DRAFT

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K1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Measure Description:





NQF Number 0059



Measure Parts 1









Additional Notes

DRAFT

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MACRA MIPS Measure.

DRAFT

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K1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) Measure Description:




NQF Number 0418

Measure Steward CMS


Measure Parts 1









DRAFT

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DRAFT

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K1-268: Pneumonia vaccination status for older adults Measure Description:



NQF Number 0043

Measure Steward CMS


Measure Parts 1









Additional Notes


PREVIEW



K1-285: Advance Care Plan Measure Description:






NQF Number 0326



Measure Parts 1









Additional Notes


PREVIEW



K1-287: Documentation of Current Medications in the Medical Record Measure Description:







NQF Number 0419

Measure Steward CMS


Measure Parts 1









DRAFT

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Additional Notes


DRAFT

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K1-300: Behavioral Health Risk Assessment (for Pregnant Women) (BHRA-CH) Measure Description:

Percentage of women, regardless of age, who gave birth during a 12-month period seen at least once for

prenatal care who received a behavioral health screening risk assessment that includes the following

screenings at the first prenatal visit: depression screening, alcohol use screening, tobacco use screening,

drug use screening (illicit and prescription, over the counter), and intimate partner violence screening.


NQF Number NA


Link to Measure Citation https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html

Measure Parts 1


Numerator Description Patients who received the following behavioral health screening risk assessments at the first prenatal visit. Depression screening • Patients who were screened for depression at the first visit. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer-administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool [e.g., PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS)]. Alcohol use screening • Patients who were screened for any alcohol use at the first visit Tobacco use screening • Patients who were screened for tobacco use at the first visit Drug use (illicit and prescription, over the counter) screening • Patients who were screened for any drug use at the first visit Intimate partner violence screening • Patients who were screened for intimate partner violence/abuse at the first visit. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Intimate partner violence screening may include a self-reported validated depression screening tool (e.g., Hurt, Insult, Threaten, and Scream [HITS], Woman Abuse Screening Tool [WAST], Partner Violence Screen [PVS], Abuse Assessment Screen [AAS]). To satisfactorily meet the numerator, ALL screening components must be performed.

Denominator Description All patients, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care.



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https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html

https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html


DSRIP Specified Setting Primary Care, Outpatient Specialty Care, OB, Hospital

Data Source TBD


Additional Notes


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K1-269: Preventive Care and Screening: Influenza Immunization Measure Description:







Measure Parts 1









Additional Notes

MACRA MIPS Measure.

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K1-358: Health literacy measure derived from the health literacy domain of the C-CAT (Tentatve Pending Further Review) Measure Description:

0-100 measure of health literacy related to patient-centered communication, derived from items on the

staff and patient surveys of the Communication Climate Assessment Toolkit


NQF Number 1898

Measure Steward American Medical Association


Measure Parts 1


Numerator Description Health literacy component of patient-centered communication: an organization should consider the health literacy level of its current and potential populations and use this information to develop a strategy for the clear communication of medical information verbally, in writing and using other media. Measure is scored based on 15 items from the patient survey of the C-CAT and 13 items from the staff survey of the C-CAT. Minimum of 100 patients responses and 50 staff responses.

Denominator Description There are two components to the target population: staff (clinical and nonclinical) and patients. Sites using this measure must obtain at least 50 staff responses and at least 100 patient responses.


Exclusions Staff respondents who do not have direct contact with patients are excluded from questions that specifically address patient contact.


Data Source Provider Tool


Additional Notes Tentatve Pending Further Review

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BUNDLE K2: RURAL EMERGENCY CARE

K2-223: Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls Measure Description:

This is a clinical process measure that assesses falls prevention in older adults. The measure has three

rates:

A) Screening for Future Fall Risk:

Percentage of patients aged 65 years and older who were screened for future fall risk at least once

within 12 months

B) Falls Risk Assessment:

Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls

completed within 12 months

C) Plan of Care for Falls:

Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls

documented within 12 months


NQF Number 0101



Measure Parts 3


Numerator Description This measure has three rates. The numerators for the three rates are as follows: A) Screening for Future Fall Risk: Patients who were screened for future fall* risk** at last once within 12 months B) Falls Risk Assessment: Patients who had a risk assessment*** for falls completed within 12 months C) Plan of Care for Falls: Patients with a plan of care**** for falls documented within 12 months. *A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force. **Risk of future falls is defined as having had had 2 or more falls in the past year or any fall with injury in the past year. ***Risk assessment is comprised of balance/gait assessment AND one or more of the following assessments: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months.

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****Plan of care must include consideration of vitamin D supplementation AND balance, strength and gait training.

Denominator Description A) Screening for Future Fall Risk: All patients aged 65 years and older seen by an eligible provider in the past year. B & C) Falls Risk Assessment & Plan of Care for Falls: All patients aged 65 years and older seen by an eligible provider in the past year with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).


Exclusions Patients who have documentation of medical reason(s) for not screening for future fall risk, undergoing a risk-assessment or having a plan of care (e.g., patient is not ambulatory) are excluded from this measure.

DSRIP Specified Setting Other



Additional Notes

MACRA MIPS Measure.

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K2-285: Advance Care Plan Measure Description:






NQF Number 0326



Measure Parts 1









Additional Notes


PREVIEW



K2-287: Documentation of Current Medications in the Medical Record Measure Description:







NQF Number 0419

Measure Steward CMS


Measure Parts 1









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Additional Notes


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K2-355: Admit Decision Time to ED Departure Time for Admitted Patients Measure Description:

Median time from admit decision time to time of departure from the emergency department for

emergency department patients admitted to inpatient status


NQF Number 0497

Measure Steward CMS


Measure Parts 1


Numerator Description Continuous Variable Statement: Time (in minutes) from admit decision time to time of departure from the emergency department for admitted patients.

Denominator Description Continuous Variable Statement: Time (in minutes) from admit decision time to time of departure from the emergency department for admitted patients.


Exclusions Patients who are not an ED Patient




Additional Notes

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K2-359: Emergency Transfer Communication Measure Measure Description:

Percentage of patients transferred to another healthcare facility whose medical record documentation

indicated that REQUIRED information was communicated to the receiving facility prior to departure

(SUBSECTION 1) OR WITHIN 60 MINUTES OF TRANSFER (SUBSECTION 2-7)


NQF Number 0291

Measure Steward University of Minnesota Rural Health Research Center


Measure Parts 1


Numerator Description Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that administrative and clinical information was communicated to the receiving facility IN AN APPROPRIATE TIME FRAME • EDTC-SUB 1 Administrative communication - Nurse to nurse communication - Physician to physician communication • EDTC-SUB 2 Patient information - Name - Address - Age - Gender - Significant others contact information - Insurance • EDTC-SUB 3 Vital signs - Pulse - Respiratory rate - Blood pressure - Oxygen saturation - Temperature - Glasgow score or other neuro assessment for trauma, cognitively altered or neuro patients only • EDTC-SUB 4 Medication information - Medications administered in ED - Allergies - Home medications • EDTC-SUB 5 Physician or practitioner generated information - History and physical - Reason for transfer and/or plan of care • EDTC-SUB 6 Nurse generated information - Assessments/interventions/response - Sensory Status (formerly Impairments) - Catheters

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- Immobilizations - Respiratory support - Oral limitations • EDTC-SUB 7 Procedures and tests - Tests and procedures done - Tests and procedure results sent

Denominator Description All emergency department patients who are transferred to another healthcare facility


Exclusions All emergency department patients not discharged to another healthcare facility.


Data Source Claims (Only), Electronic Health Record (Only), Imaging-Diagnostic, Laboratory, Other, Paper Records, Pharmacy, Registry


Additional Notes

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L1: LOCAL HEALTH DEPARTMENTS

L1-103: Controlling High Blood Pressure Measure Description:




NQF Number 0018



Measure Parts 1












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L1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention Measure Description:




NQF Number 0028



Measure Parts 1












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L1-107: Colorectal Cancer Screening Measure Description:

The percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer.


NQF Number 0034



Measure Parts 1


Numerator Description One or more screenings for colorectal cancer. Any of the following meet criteria: - Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type. - Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year. - Colonoscopy during the measurement year or the nine years prior to the measurement year.

Denominator Description Patients 51–75 years of age as of the end of the measurement year.


Exclusions Exclude patients with a diagnosis of colorectal cancer or total colectomy


Data Source Claims (Only), Imaging-Diagnostic, Laboratory, Paper Records


Additional Notes


Measure.

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L1-108: Childhood Immunization Status (CIS) Measure Description:

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP);

three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB);

three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A

(HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The

measure calculates a rate for each vaccine.


NQF Number 0038



Measure Parts 1


Numerator Description Children who have evidence showing they received all recommended vaccines by their second birthday: • Four diphtheria, tetanus and acellular pertussis (DtaP) • Three polio (IPV) • One measles, mumps and rubella (MMR) • Three H influenza type B (HiB) • Three hepatitis B (HepB) • One chicken pox (VZV) • Four pneumococcal conjugate (PCV) • One hepatitis A (HepA) • Two or three rotavirus (RV); and, • Two influenza (flu)

Denominator Description Children who turn 2 years of age during the measurement year.


Exclusions Exclude children who had a contraindication for a specific vaccine from the denominator for all antigen rates. The denominator for all rates must be the same.




Additional Notes

CMS Alignment: Child Core Set; MACRA MIPS Measure; Proposed 2018 MCO P4Q Measure.

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L1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Measure Description:





NQF Number 0059



Measure Parts 1









Additional Notes

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MACRA MIPS Measure.

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L1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Measure Description:




Normal Parameters:


Age 18 – 64 years BMI >= 18.5 and < 25



Measure Steward CMS


Measure Parts 1






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Data Source Other


Additional Notes



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L1-160: Follow-Up After Hospitalization for Mental Illness Measure Description:







NQF Number 0576



Measure Parts 2






DRAFT

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Additional Notes


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L1-186: Breast Cancer Screening Measure Description:

The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.


NQF Number 2372



Measure Parts 1


Numerator Description Women who received a mammogram to screen for breast cancer.

Denominator Description Women 52-74 years as of December 31 of the measurement year Note: this denominator statement captures women age 50-74 years; it is structured to account for the look-back period for mammograms.


Exclusions Bilateral mastectomy any time during the member’s history through December 31 of the measurement year. Any of the following meet criteria for bilateral mastectomy: 1) Bilateral mastectomy 2) Unilateral mastectomy with a bilateral modifier 3) Two unilateral mastectomies on different dates of service and 4) Both of the following (on the same date of service): Unilateral mastectomy with a right-side modifier and unilateral mastectomy with a left-side modifier.




Additional Notes


Consensus OB/GYN Measures; MACRA MIPS Measure.

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L1-205: Third next available appointment Measure Description:

This measure is used to assess the average number of days to the third next available appointment for

an office visit* for each clinic and/or department. This measure does not differentiate between "new"

and "established" patients.

*Office Visit: A patient encounter with a health care provider in an office, clinic, or ambulatory care

facility as an outpatient.


NQF Number NA

Measure Steward Wisconsin Collaborative for Healthcare Quality


https://www.qualitymeasures.ahrq.gov/summaries/summary/23918/access-time-to-third-next-available-appointment-for-an-office-visit

Measure Parts 1

Benchmark Description

NA HPL: NA MPL: NA

Numerator Description

Continuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department. The measure will take into account calendar days, including weekends, holidays and clinician days off.

Denominator Description

This measure applies to providers within a reported clinic and/or department (see the related "Denominator Inclusions/Exclusions" field)

Inclusions Providers: All providers are included. Full-time and part-time providers are included, regardless of the number of hours s/he practices per week. Providers who truly job share are counted as one provider (i.e., they share one schedule, and/or they work separate day and share coverage of one practice). When measuring a care team, each member of the care team is counted separately (i.e., MD, NP, PA). If a provider is practicing in a specialty other than the one which s/he is board certified, the provider should be included in the specialty in which s/he is practicing. For providers practicing at more than 1 location, measure days to third next available for only the provider's primary location as long as the provider is at that location 51%+ of their time. New providers who started seeing patients during the reporting period and have an active schedule should be included. Locums are included in the measure only if they are assigned to a specific site for an extended period of time (greater than 4 weeks) and provide continuity care to a panel of patients. Mid-Level providers are included in the measure (NP, PA, CNM). Mid-Level providers should have continuity practice and their own schedule available to see patients.

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Resident Providers are to be included if they have an active schedule AND are considered a Primary Care Provider within the organization. Providers with closed practices should be included. They still have to schedule their current patients. In addition, it may not be clear when they start seeing new patients again. Departments: Primary Care General Internal Medicine Family Practice Pediatrics with the focus on generalists, not specialists Med/Peds (physicians who see both adults and children) Specialty Care Obstetrics Physical exam - New OB visit

Exclusions Exclude clinicians who do not practice for an extended period of time (greater than 4 weeks) due to maternity leave, sabbatical, family medical leave. Mid-Level providers who function only as an "extender," overflow to another practice, or urgent care should not be included. Exclude Resident Providers if they are not considered a Primary Care Provider, have an inconsistent schedule, and a restricted patient panel.

DSRIP Specified Setting

Any

Data Source Provider data



PREVIEW


L1-207: Diabetes care: BP control (<140/90mm Hg) Measure Description:




NQF Number 0061



Measure Parts 1









Additional Notes

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L1-210: PQRS #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Measure Description:





NQF Number NA

Measure Steward CMS


Measure Parts 1







Data Source TBD


Additional Notes

MACRA MIPS Measure.

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L1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Measure Description:







NQF Number 0024



Measure Parts 3









Additional Notes


Measure.

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L1-224: Dental Sealant: Children Measure Description:

Increase the proportion of children aged 6 to 9 years who have received dental sealants on one or more

of their permanent first molar teeth


NQF Number NA


Link to Measure Citation https://www.healthypeople.gov/node/5001/data_details

Measure Parts 1


Numerator Description Number of children aged 6 to 9 with a clinical confirmation of dental sealants applied to one or more first permanent molars

Denominator Description Number of children aged 6 to 9 with at least one permanent first molar present and valid sealant codes for at least one permanent first molar




Data Source TBD


Additional Notes

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https://www.healthypeople.gov/node/5001/data_details


L1-225: Dental Caries: Children Measure Description:

Percentage of children with untreated dental caries


NQF Number NA



Measure Parts 1


Numerator Description Number of children with untreated dental caries

Denominator Description Total number of children that have seen a dental provider within the measurement period




Data Source Administrative/Clinical data sources; supplemental data sources


Additional Notes

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L1-227: Dental Caries: Adults Measure Description:

Percentage of adults aged 18 or more years with untreated dental decay


NQF Number NA



Measure Parts 1


Numerator Description Number of adults aged 18 years or more with coronal caries that has not been restored in at least one permanent tooth

Denominator Description Number of adults aged 18 or more years with at least one permanent tooth present and valid coronal caries codes for at least one permanent tooth






Additional Notes Measure title changed to Dental Caries: Adults

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L1-231: Preventive Services for Children at Elevated Caries Risk - Modified Denominator Measure Description:

Percentage of enrolled children who are at “elevated” risk (i.e., “moderate” or “high”) who received a

topical fluoride application and/or sealants within the reporting year


NQF Number NA


Link to Measure Citation http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ DQA_2017_Dental_Services_Preventive_Services.pdf?la=en

Measure Parts 2


Numerator Description Unduplicated number of children at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants as a dental service

Denominator Description Unduplicated number of enrolled children at “elevated” risk (i.e., “moderate” or “high”)




Data Source Administrative enrollment and claims data



PREVIEW


L1-235: Post-Partum Follow-Up and Care Coordination (PQRS #336) Measure Description:

Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for

post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education,

post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and

family and contraceptive planning


NQF Number NA

Measure Steward CMS


Measure Parts 1


Numerator Description Patients receiving the following at a post-partum visit: - Breast feeding evaluation and education, including patient-reported breast feeding - Post-partum depression screening - Post-partum glucose screening for gestational diabetes patients and - Family and contraceptive planning Definitions: Breast Feeding Evaluation and Education – Patients who were evaluated for breast feeding before or at 8 weeks post-partum. Post-Partum Depression Screening – Patients who were screened for post-partum depression before or at 8 weeks post-partum. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool (e.g., PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS). Post-Partum Glucose Screening for Gestational Diabetes – Patients who were diagnosed with gestational diabetes during pregnancy who were screened with a glucose screen before or at 8 weeks post-partum. Family and Contraceptive Planning – Patients who were provided family and contraceptive planning and education (including contraception, if necessary) before or at 8 weeks post-partum. Numerator Instruction: To satisfactorily meet the numerator ALL components (breast feeding evaluation and education, post-partum depression screening, family and contraceptive planning and post-partum glucose screening for patients with gestational diabetes) must be performed.

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Denominator Description All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth

Inclusions Denominator: All patients, regardless of age AND Patient encounter during reporting period (CPT): 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622 AND Post-partum Care Visit before or at 8 weeks post-delivery Numerator: Performance Met: Post-partum screenings, evaluations and education performed (G9357)

Exclusions Numerator: Performance Not Met: Post-partum screenings, evaluations and education not performed (G9358)




Additional Notes


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L1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits) Measure Description:

The percentage of children 15 months old who had the recommended number of well-child visits with a

PCP during their first 15 months of life.


NQF Number 1392



Measure Parts 1


Numerator Description Children who received the following number of well-child visits with a PCP during their first 15 months of life: - No well-child visits - One well-child visit - Two well-child visits - Three well-child visits - Four well-child visits - Five well-child visits - Six or more well-child visits

Denominator Description Children 15 months old during the measurement year.






Additional Notes


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L1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons Measure Description:

The percentage of individuals receiving the project intervention(s) who had a potentially preventable

admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period


NQF Number NA



Measure Parts 1


Numerator Description The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.

Denominator Description Number of individuals receiving project intervention(s)

Inclusions Denominator: Number of individuals receiving project intervention(s) Numerator: If an individual has more than one jail booking occurrence within the measurement period, that individual would only be counted once in the numerator



Data Source Administrative Claims, Electronic Health Record, Clinical Data, Registration data; Criminal justice system records, local mental health authority and state mental health data system records


Additional Notes

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L1-242: Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) Measure Description:

Rate of Emergency Department (ED) utilization for ACSC:

- Grand mal status and other epileptic convulsions

- Chronic obstructive pulmonary diseases

- Asthma

- Heart failure and pulmonary edema

- Hypertension

- Angina, or

- Diabetes


NQF Number NA



Measure Parts 1


Numerator Description Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period


Inclusions Any ED visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period: Grand mal status and other epileptic convulsions: 345 Chronic obstructive pulmonary diseases: 466.0 (only with secondary diagnosis of 491, 492, 494, 496), 491, 492, 494, 496 Asthma: 493 Heart failure and pulmonary edema: 402.01, 402.11, 402.91, 428, 518.4 Hypertension: 401.0, 401.9, 402.00, 402.10, 402.90 Angina: 411.1, 411.8, 413 Diabetes: 250.0, 250.1, 250.2, 250.3,250.8, 250.9

Exclusions The following diagnostic codes should be excluded: Grand mal status and other epileptic convulsions: None Chronic obstructive pulmonary diseases: None Asthma: None Heart failure and pulmonary edema: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7

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Hypertension: procedures: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 Angina: Procedure codes 01-86.99 Diabetes: Diabetes with renal manifestations [250.4], diabetes with ophthalmic manifestations [250.5], diabetes with neurological manifestations [250.6] and diabetes with peripheral circulatory disorders [250.7]




Additional Notes

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L1-268: Pneumonia vaccination status for older adults Measure Description:



NQF Number 0043

Measure Steward CMS


Measure Parts 1









Additional Notes


PREVIEW



L1-269: Preventive Care and Screening: Influenza Immunization Measure Description:







Measure Parts 1









Additional Notes

MACRA MIPS Measure.

DRAFT

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L1-271: Immunization for Adolescents- Tdap/TD and MCV Measure Description:

The percentage of adolescents 13 years of age who had the recommended immunizations

(meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or

one tetanus, diphtheria toxoids vaccine (Td)) by their 13th birthday.


NQF Number 1407



Measure Parts 1


Numerator Description Adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.

Denominator Description Adolescents who turn 13 years of age during the measurement year.


Exclusions Exclude adolescents who had a contraindication for a specific vaccine from the denominator for all antigen rates and the combination rate. The denominator for all rates must be the same. Contraindicated adolescents may be excluded only if administrative data do not indicate that the contraindicated immunization was rendered. Either of the following meet exclusion criteria: • Anaphylactic reaction to the vaccine or its components (Anaphylactic Reaction Due To Vaccination Value Set) any time on or before the member’s 13th birthday. • Anaphylactic reaction to the vaccine or its components (Anaphylactic Reaction Due To Serum Value Set), with a date of service prior to October 1, 2011.




Additional Notes Updated to include HPV


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L1-272: Adults (18+ years) Immunization status Measure Description:

Percentage of adult patients 18 years and older who are up-to-date with the following immunizations:

-One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years

-Varicella – two doses or history of disease up to year 1995

-Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older

-One influenza within last year

-Herpes zoster/shingles (patients 60 years and older)


NQF Number NA

Measure Steward Institute for Clinical Systems Improvement


Measure Parts 1


Numerator Description Number of patients who are up-to-date with following immunizations: -One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years -Varicella – two doses or history of disease up to year 1995 -Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older -One influenza dose within the last year -Herpes zoster/shingles (patients 60 years and older)

Denominator Description Number of patients 18 years and older during the specified measurement period*


Exclusions Denominator Exclusions: Patients with immunization contraindications listed in the medical record should be excluded


Data Source Clinical Data, Electronic Health Record, Administrative Claims


Additional Notes

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L1-280: Chlamydia Screening in Women (CHL) Measure Description:




NQF Number 0033



Measure Parts 1









Additional Notes


PREVIEW



L1-343: Syphilis positive screening rates Measure Description:

The percentage of newly diagnosed primary or secondary syphilis during the measurement period.

Providers will report three separate rates:

Rate #1: The percentage of newly diagnosed primary or secondary syphilis among all individuals (males

and females) during the measurement period.

Rate #2: The percentage of newly diagnosed primary or secondary syphilis among males during the

measurement period

Rate #3: The percentage of newly diagnosed primary or secondary syphilis among females during the

measurement period


NQF Number NA

Measure Steward CDC

Link to Measure Citation http://www.healthindicators.gov/Indicators/Syphilis-primary-and-secondary-females-per-100000_1480/Profile

Measure Parts 3


Numerator Description The numerators for the three rates to be reported: Rate #1: Number of new reported cases of primary and secondary syphilis among all individuals (males and females) during the measurement period Rate #2: Number of new reported cases of primary or secondary syphilis among males during the measurement period Rate #3: Number of new reported cases of primary and secondary syphilis among females during the measurement period

Denominator Description The denominators for the three rates to be reported: Rate #1: Number of individuals (i.e. males and females) Rate #2: Number of males Rate #3: Number of females




Data Source TBD


Additional Notes

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http://www.healthindicators.gov/Indicators/Syphilis-primary-and-secondary-females-per-100000_1480/Profile

http://www.healthindicators.gov/Indicators/Syphilis-primary-and-secondary-females-per-100000_1480/Profile


L1-344: Follow-up after Treatment for Primary or Secondary Syphilis Measure Description:

Percentage of individuals who undergo follow-up clinical and/or serologic evaluation at 6-months after

treatment for primary or secondary syphilis


NQF Number NA

Measure Steward CDC

Link to Measure Citation http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

Measure Parts 1


Numerator Description The number of individuals who have undergone treatment for primary or secondary syphilis and complete clinical and/or serologic testing at 6 months

Denominator Description Total number of individuals who have undergone treatment for primary or secondary syphilis.




Data Source TBD


Additional Notes

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http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf


L1-345: Gonorrhea Positive Screening Rates Measure Description:

The percentage of newly diagnosed cases of gonorrhea during the measurement period. Providers will

report three separate rates:

Rate #1: The percentage of newly diagnosed gonorrhea among all individuals (males and females) during

the measurement period.

Rate #2: The percentage of newly diagnosed gonorrhea among males during the measurement period

Rate #3: The percentage of newly diagnosed gonorrhea among females during the measurement period


NQF Number NA

Measure Steward CDC


Measure Parts 3


Numerator Description The numerators for the three rates to be reported: Rate #1: Number of new reported cases of gonorrhea among all cases (males and females) during the measurement period Rate #2: Number of new reported cases of gonorrhea among males during the measurement period Rate #3: Number of new reported cases of gonorrhea among females during the measurement period

Denominator Description The denominators for the three rates to be reported: Rate #1: Number of individuals (i.e. total number of females and males) Rate #2: Number of males Rate #3: Number of females




Data Source TBD


Additional Notes

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L1-346: Follow-up testing for N. gonorrhoeae among recently infected men and women Measure Description:

The proportion of men and women who undergo follow up testing for uncomplicated Gonorrhea 3-

months after treatment during the measurement period.


NQF Number NA

Measure Steward CDC


Measure Parts 1


Numerator Description The number of individuals who undergo follow-up testing for uncomplicated Gonorrhea 3-months after treatment.

Denominator Description Total number of individuals treated for uncomplicated Gonorrhea.




Data Source TBD


Additional Notes

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L1-347: Latent Tuberculosis Infection (LTBI) treatment rate Measure Description:

Percentage of patients with latent tuberculosis infection who complete a course of treatment.


NQF Number NA

Measure Steward CDC


Measure Parts 1


Numerator Description Individuals from the denominator that completed a LTBI treatment regimen

Denominator Description Total number of individuals identified with Latent Tuberculosis Infection (LTBI) that initiated (accepted) a LTBI treatment regimen.



DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Hospital, Other

Data Source TBD


Additional Notes

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L1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates) Measure Description:



NQF Number NA

Measure Steward NA


Measure Parts 2







Data Source TBD


Additional Notes Reported as two rates DRAFT

PREVIEW





M1: COMMUNITY MENTAL HEALTH CENTERS

M1-100: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) Measure Description:

The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD)

dependence who received the following.

- Initiation of AOD Treatment. The percentage of patients who initiate treatment through an inpatient

AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days

of the diagnosis.

- Engagement of AOD Treatment. The percentage of patients who initiated treatment and who had two

or more additional services with a diagnosis of AOD within 30 days of the initiation visit.


NQF Number 0004



Measure Parts 2

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: Initiation: 0.4628 Engagement: 0.1695 MPL: Initiation: 0.3439 Engagement: 0.0692

Numerator Description Initiation of AOD Dependence Treatment: Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the index episode start date. Engagement of AOD Treatment: Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days after the date of the Initiation encounter (inclusive).

Denominator Description Patients age 13 years of age and older who were diagnosed with a new episode of alcohol or other drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15).


Exclusions Exclude patients who had a claim/encounter with a diagnosis of AOD during the 60 days (2 months) before the Index Episode Start Date. (See corresponding Excel document for the AOD Dependence Value Set) Exclude from the denominator for both indicators (Initiation of AOD Treatment and Engagement of AOD Treatment) patients whose initiation of treatment event is an inpatient stay with a discharge date after December 1 of the measurement year.

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DSRIP Specified Setting Behavioral Health: Inpatient, Behavioral Health: Outpatient, Primary Care, Outpatient Specialty Care, Hospital, Urgent Care - Ambulatory



Additional Notes


DRAFT

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M1-103: Controlling High Blood Pressure Measure Description:




NQF Number 0018



Measure Parts 1












DRAFT

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M1-104: Medical Assistance with Smoking and Tobacco Use Cessation (MSC) - Modified Denominator Measure Description:

Assesses different facets of providing medical assistance with smoking and tobacco use cessation:

Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18

years of age and older who were current smokers or tobacco users and who received advice to quit

during the measurement year.

Discussing Cessation Medications: A rolling average represents the percentage of patients 18 years of

age and older who were current smokers or tobacco users and who discussed or were recommended

cessation medications during the measurement year.

Discussing Cessation Strategies: A rolling average represents the percentage of patients 18 years of age

and older who were current smokers or tobacco users and who discussed or were provided cessation

methods or strategies during the measurement year.





Measure Parts 3

Benchmark Description National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles) HPL: Advising Smokers to Quit: 0.8185 Discussing Cessation Medications: 0.5839 Discussing Cessation Strategies: 0.5175 MPL: Advising Smokers to Quit: 0.7314 Discussing Cessation Medications: 0.4301 Discussing Cessation Strategies: 0.3886

Numerator Description Component 1: Advising Smokers and Tobacco Users to Quit (ASTQ) Patients who received advice to quit smoking or using tobacco from their doctor or health provider Component 2: Discussing Cessation Medications (DSCM) Patients who discussed or received recommendations on smoking or tobacco cessation medications from their doctor or health provider Component 3: Discussing Cessation Strategies (DSCS) Patients who discussed or received recommendations on smoking or tobacco cessation methods and strategies other than medication from their doctor or health provider

Denominator Description Patients 18 years and older who indicated that they were current smokers or tobacco users during the measurement year.






DRAFT

PREVIEW



Additional Notes


DRAFT

PREVIEW


M1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention Measure Description:




NQF Number 0028



Measure Parts 1












DRAFT

PREVIEW



M1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Measure Description:





NQF Number 0059



Measure Parts 1









Additional Notes

DRAFT

PREVIEW




MACRA MIPS Measure.

DRAFT

PREVIEW


M1-124: Medication Reconciliation Post-Discharge Measure Description:

The percentage of discharges for patients 18 years of age and older for whom the discharge medication

list was reconciled with the current medication list in the outpatient medical record by a prescribing

practitioner, clinical pharmacist or registered nurse.


NQF Number 0097



Measure Parts 1


Numerator Description Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on or within 30 days of discharge. Medication reconciliation is defined as a type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record.

Denominator Description All discharges from an in-patient setting for patients who are 18 years and older.


Exclusions The following exclusions are applicable to the Health Plan Level measure. - Exclude both the initial discharge and the readmission/direct transfer discharge if the readmission/direct transfer discharge occurs after December 1 of the measurement year. - If the discharge is followed by a readmission or direct transfer to an acute or non-acute facility within the 30-day follow-up period, count only the readmission discharge or the discharge from the facility to which the patient was transferred.




Additional Notes

CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; MACRA MIPS High

Priority Measure.

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M1-125: Antidepressant Medication Management (AMM-AD) Measure Description:

The percentage of patients 18 years of age and older with a diagnosis of major depression and were

treated with antidepressant medication, and who remained on an antidepressant medication treatment.

Two rates are reported.

a) Effective Acute Phase Treatment. The percentage of patients who remained on an antidepressant

medication for at least 84 days (12 weeks).

b) Effective Continuation Phase Treatment. The percentage of patients who remained on an

antidepressant medication for at least 180 days (6 months).


NQF Number 0105



Measure Parts 2


Numerator Description Adults 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment.

Denominator Description Patients 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication.


Exclusions Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients who did not have a diagnosis of major depression in an inpatient, outpatient, ED, intensive outpatient or partial hospitalization setting during the 121-day period from 60 days prior to the IPSD, through the IPSD and the 60 days after the IPSD. Exclude patients who filled a prescription for an antidepressant 105 days prior to the IPSD.

DSRIP Specified Setting Behavioral Health: Outpatient



Additional Notes


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M1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) Measure Description:




NQF Number 0418

Measure Steward CMS


Measure Parts 1









DRAFT

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DRAFT

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M1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Measure Description:




Normal Parameters:


Age 18 – 64 years BMI >= 18.5 and < 25



Measure Steward CMS


Measure Parts 1






DRAFT

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Data Source Other


Additional Notes



DRAFT

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M1-160: Follow-Up After Hospitalization for Mental Illness Measure Description:







NQF Number 0576



Measure Parts 2






DRAFT

PREVIEW







Additional Notes


DRAFT

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M1-165: Depression Remission at 12 Months Measure Description:


demonstrate remission at twelve months defined as a PHQ-9 score less than 5. This measure applies to

both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need

for treatment.

This measure additionally promotes ongoing contact between the patient and provider as patients who

do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the

denominator.


NQF Number 0710



Measure Parts 1


Numerator Description Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five.







Additional Notes



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M1-180: Adherence to Antipsychotics for Individuals with Schizophrenia (SAA-AD) Measure Description:

Percentage of individuals at least 18 years of age as of the beginning of the measurement period with

schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic

medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications

during the measurement period (12 consecutive months).


NQF Number 1879

Measure Steward CMS


Measure Parts 1


Numerator Description Individuals with schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic medications and have a PDC of at least 0.8 for antipsychotic medications.

Denominator Description Individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder and at least two prescription drug claims for antipsychotic medications during the measurement period (12 consecutive months).


Exclusions Individuals with any diagnosis of dementia during the measurement period.


Data Source Claims (Only), Other, Pharmacy


Additional Notes


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M1-181: Depression Response at Twelve Months- Progress Towards Remission Measure Description:


demonstrate a response to treatment at twelve months defined as a PHQ-9 score that is reduced by

50% or greater from the initial PHQ-9 score. This measure applies to both patients with newly diagnosed

and existing depression identified during the defined measurement period whose current PHQ-9 score

indicates a need for treatment.

This measure additionally promotes ongoing contact between the patient and provider as patients who

do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the

denominator.


NQF Number 1885



Measure Parts 0


Numerator Description Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve a response at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score.

Denominator Description Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine.


Exclusions Patients who die, are a permanent resident of a nursing home or are enrolled in hospice or palliative care services are excluded from this measure. Additionally, patients who have a diagnosis (in any position) of bipolar or personality disorder are excluded.

DSRIP Specified Setting Behavioral Health: Outpatient, Clinician Office/Clinic

Data Source Electronic Health Record (Only), Other, Paper Records, Patient Reported Data


Additional Notes

CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures;

DRAFT

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M1-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD) Measure Description:

The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were

dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.


NQF Number 1932



Measure Parts 1


Numerator Description Among patients 18-64 years old with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year.

Denominator Description Patients ages 18 to 64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication.


Exclusions Exclude members who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients with diabetes during the measurement year or the year prior to the measurement year. Exclude patients who had no antipsychotic medications dispensed during the measurement year.


Data Source Claims (Only), Electronic Health Record (Only), Laboratory, Pharmacy


Additional Notes

CMS Alignment: Adult Core Set; Proposed 2018 MCO P4Q Measure.

DRAFT

PREVIEW



M1-203: PQRS #400: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Measure Description:

Percentage of patients aged 18 years and older with one or more of the following: a history of injection

drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate

in the years 1945–1965 who received one- time screening for hepatitis C virus (HCV) infection


NQF Number NA / 3059 eMeasure


Link to Measure Citation https://pqrs.cms.gov/dataset/2016-PQRS-Measure-400-11-17-2015/kx88-j5sg http://www.qualityforum.org/QPS/3059

Measure Parts 1


Numerator Description Patients who received one-time screening for HCV infection

Denominator Description All patients aged 18 years and older who were seen twice for any visit or who had at least one preventive visit within the 12 month reporting period with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965


Exclusions Denominator Exclusions: Patients with a diagnosis of chronic hepatitis C Denominator Exceptions: Documentation of medical reason(s) for not receiving one-time screening for HCV infection (eg, decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) Documentation of patient reason(s) for not receiving one-time screening for HCV infection (eg, patient declined, other patient reasons)




Additional Notes


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M1-205: Third next available appointment Measure Description:

This measure is used to assess the average number of days to the third next available appointment for

an office visit* for each clinic and/or department. This measure does not differentiate between "new"

and "established" patients.

*Office Visit: A patient encounter with a health care provider in an office, clinic, or ambulatory care

facility as an outpatient.


NQF Number NA

Measure Steward Wisconsin Collaborative for Healthcare Quality



Measure Parts 1

Benchmark Description

NA HPL: NA MPL: NA

Numerator Description

Continuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department. The measure will take into account calendar days, including weekends, holidays and clinician days off.

Denominator Description

This measure applies to providers within a reported clinic and/or department (see the related "Denominator Inclusions/Exclusions" field)

Inclusions Providers: All providers are included. Full-time and part-time providers are included, regardless of the number of hours s/he practices per week. Providers who truly job share are counted as one provider (i.e., they share one schedule, and/or they work separate day and share coverage of one practice). When measuring a care team, each member of the care team is counted separately (i.e., MD, NP, PA). If a provider is practicing in a specialty other than the one which s/he is board certified, the provider should be included in the specialty in which s/he is practicing. For providers practicing at more than 1 location, measure days to third next available for only the provider's primary location as long as the provider is at that location 51%+ of their time. New providers who started seeing patients during the reporting period and have an active schedule should be included. Locums are included in the measure only if they are assigned to a specific site for an extended period of time (greater than 4 weeks) and provide continuity care to a panel of patients. Mid-Level providers are included in the measure (NP, PA, CNM). Mid-Level providers should have continuity practice and their own schedule available to see patients.

DRAFT

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Resident Providers are to be included if they have an active schedule AND are considered a Primary Care Provider within the organization. Providers with closed practices should be included. They still have to schedule their current patients. In addition, it may not be clear when they start seeing new patients again. Departments: Primary Care General Internal Medicine Family Practice Pediatrics with the focus on generalists, not specialists Med/Peds (physicians who see both adults and children) Specialty Care Obstetrics Physical exam - New OB visit

Exclusions Exclude clinicians who do not practice for an extended period of time (greater than 4 weeks) due to maternity leave, sabbatical, family medical leave. Mid-Level providers who function only as an "extender," overflow to another practice, or urgent care should not be included. Exclude Resident Providers if they are not considered a Primary Care Provider, have an inconsistent schedule, and a restricted patient panel.

DSRIP Specified Setting

Any

Data Source Provider data



PREVIEW


M1-207: Diabetes care: BP control (<140/90mm Hg) Measure Description:




NQF Number 0061



Measure Parts 1









Additional Notes

DRAFT

PREVIEW



M1-208: Comprehensive Diabetes Care LDL-C Screening Measure Description:




NQF Number 0063



Measure Parts 1









Additional Notes

DRAFT

PREVIEW



M1-210: PQRS #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Measure Description:





NQF Number NA

Measure Steward CMS


Measure Parts 1







Data Source TBD


Additional Notes

MACRA MIPS Measure.

DRAFT

PREVIEW




M1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Measure Description:







NQF Number 0024



Measure Parts 3









Additional Notes


Measure.

DRAFT

PREVIEW



M1-216: Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate Measure Description:

Risk adjusted rate of hospital admissions for Behavioral Health /Substance Abuse (BH/SA) that had at

least one readmission for any reason within 30 days of discharge for patients 18 years of age and older.





measurement year.


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Observed (Actual) rate of readmissions within 30 days following an Index Admission for BH/SA during the measurement year. The Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk BH/SA admissions during the measurement period.

Denominator Description Expected (risk-adjusted) rate of readmissions for BH/SA during the measurement year. The Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.




Data Source Administrative Claims, Electronic Health Records


Additional Notes

DRAFT

PREVIEW





M1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons Measure Description:

The percentage of individuals receiving the project intervention(s) who had a potentially preventable

admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period


NQF Number NA



Measure Parts 1


Numerator Description The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.

Denominator Description Number of individuals receiving project intervention(s)

Inclusions Denominator: Number of individuals receiving project intervention(s) Numerator: If an individual has more than one jail booking occurrence within the measurement period, that individual would only be counted once in the numerator



Data Source Administrative Claims, Electronic Health Record, Clinical Data, Registration data; Criminal justice system records, local mental health authority and state mental health data system records


Additional Notes

DRAFT

PREVIEW





M1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD) Measure Description:

The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication

who had at least three follow-up care visits within a 10-month period, one of which is within 30 days of

when the first ADHD medication was dispensed.

An Initiation Phase Rate and Continuation and Maintenance Phase Rate are reported.


NQF Number 0108



Measure Parts 2


Numerator Description This measure assesses the receipt of follow-up visits for children prescribed ADHD medication. Two rates are reported. 1. INITIATION PHASE: The percentage of children between 6 and 12 years of age who were newly prescribed ADHD medication who had one follow-up visit with a prescribing practitioner within 30 days. 2. CONTINUATION AND MAINTENANCE PHASE: The percentage of children between 6 and 12 years of age newly prescribed ADHD medication and remained on the medication for at least 210 days, who had, in addition to the visit in the Initiative Phase, at least two follow-up visits with a practitioner in the 9 months subsequent to the Initiation Phase.

Denominator Description Children 6-12 years of age newly prescribed ADHD medication.


Exclusions Children with a diagnosis of narcolepsy




Additional Notes


DRAFT

PREVIEW



M1-256: Initiation of Depression Treatment Measure Description:

The proportion of individuals diagnosed with major depression that have filled at least one

antidepressant prescription or had at least three psychotherapy visits during the 5-month period after

diagnosis.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=ROST0002D&POP=0

Measure Parts 1


Numerator Description Patients in the denominator who filled at least one antidepressant prescription or had at least three psychotherapy visits during the 5-month period after diagnosis.

Denominator Description All patients seen in primary care during a specified period who had major depression based on a structured assessment administered independent of the clinical visit.




Data Source Medical Record; Patient Survey/Instrument



PREVIEW

http://www.cqaimh.org/Report.asp?Code=ROST0002D&POP=0


M1-257: Care Planning for Dual Diagnosis Measure Description:

Percentage of patients with dual diagnosis undergoing case management services who have a

documented plan to address both conditions.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=TENN0017D&POP=5

Measure Parts 1


Numerator Description Those individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions.

Denominator Description The number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder during a six-month period.







PREVIEW

http://www.cqaimh.org/Report.asp?Code=TENN0017D&POP=5


M1-259: Assignment of Primary Care Physician to Individuals with Schizophrenia Measure Description:

The percentage of individuals with a primary diagnosis of schizophrenia that have been assigned a

primary care physician.


NQF Number NA



Measure Parts 1


Numerator Description The number of individuals in the denominator who were assigned a primary care physician.








PREVIEW



M1-260: Annual Physical Exam for Persons with Mental Illness Measure Description:

The percentage of individuals receiving services for a primary psychiatric disorder whose medical

records document receipt of a physical exam during the measurement year.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=MHSI0002D&POP=0

Measure Parts 1


Numerator Description Individuals from the denominator whose medical record documents receipt of a physical examination within the specified 12-month period.

Denominator Description The total number of individuals receiving services for a primary psychiatric disorder during a specified 12- month reporting period.






Additional Notes

DRAFT

PREVIEW

http://www.cqaimh.org/Report.asp?Code=MHSI0002D&POP=0


M1-261: Assessment for Substance Abuse Problems of Psychiatric Patients Measure Description:

The percentage of individuals who received an assessment for substance abuse problems.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=APAT0005D&POP=5

Measure Parts 1


Numerator Description Number of patients in the denominator whose medical record indicates explicit evidence of assessment of current and/or past substance use disorders.

Denominator Description Total number of patients in a plan who received psychiatric evaluations within a specified period of time.



DSRIP Specified Setting Behavioral Health Outpatient

Data Source TBD


Additional Notes

DRAFT

PREVIEW

http://www.cqaimh.org/Report.asp?Code=APAT0005D&POP=5


M1-262: Assessment of Risk to Self/Others Measure Description:

The percentage of individuals with depression who received an evaluation of suicidal/homicidal ideation

(SI/HI) and associated risks.

Individuals with major depression are at higher risk for suicide than individuals in the general

population.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=JCAH0003D&POP=0

Measure Parts 1


Numerator Description Patients from the denominator whose medical record of the formal evaluation contains specific documentation of the patient's potential to harm self or others.

Denominator Description The number of patients diagnosed with a depressive disorder during a formal evaluation.







PREVIEW

http://www.cqaimh.org/Report.asp?Code=JCAH0003D&POP=0


M1-263: Assessment for Psychosocial Issues of Psychiatric Patients Measure Description:

The percentage of individuals who received an assessment of risk to self or others.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=APAG0003D&POP=0

Measure Parts 1


Numerator Description Individuals in the denominator whose medical record documents a psychosocial/developmental history. [Components include major life events, history of abuse or trauma, levels of functioning in family and social roles.]

Denominator Description All individuals age 18 and older who undergo a psychiatric evaluation during a specified period.




Data Source TBD


Additional Notes

DRAFT

PREVIEW

http://www.cqaimh.org/Report.asp?Code=APAG0003D&POP=0


M1-264: Vocational Rehabilitation for Schizophrenia Measure Description:

The percentage of individuals who received an assessment for Vocational Rehabilitation.


NQF Number NA


Link to Measure Citation http://www.cqaimh.org/Report.asp?Code=PORT0011D&POP=0

Measure Parts 1


Numerator Description Individuals in the denominator who: i) Report participating in a program to help them find a job or vocational rehabilitation is prescribed in their treatment plan; or ii) Report receiving assistance from an employment specialist

Denominator Description Individuals, 18 years or older, in active treatment for schizophrenia who at a specified point in time: i) Report in a survey that they are currently employed and they have a prior work history or are actively looking for a job; or ii) Are currently employed




Data Source TBD


Additional Notes

DRAFT

PREVIEW

http://www.cqaimh.org/Report.asp?Code=PORT0011D&POP=0


M1-265: Housing Assessment for Individuals with Schizophrenia Measure Description:

The percentage of individuals with Schizophrenia whose housing quality was assessed


NQF Number NA



Measure Parts 1


Numerator Description The number of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation.








PREVIEW



M1-266: Independent Living Skills Assessment for Individuals with Schizophrenia Measure Description:

The percentage of patients who received an assessment of independent living skills


NQF Number NA



Measure Parts 1


Numerator Description Patients in the denominator who received an assessment of independent living skills.

Denominator Description Patients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.






Additional Notes

DRAFT

PREVIEW



M1-280: Chlamydia Screening in Women (CHL) Measure Description:




NQF Number 0033



Measure Parts 1









Additional Notes


PREVIEW



M1-286: Depression Remission at Six Months Measure Description:


demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both

patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for

treatment. This measure additionally promotes ongoing contact between the patient and provider as

patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the

denominator.


NQF Number 0711



Measure Parts 1


Numerator Description Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five.




DSRIP Specified Setting Primary Care, Outpatient Specialty Care, Behavioral Health: Outpatient





DRAFT

PREVIEW



M1-287: Documentation of Current Medications in the Medical Record Measure Description:







NQF Number 0419

Measure Steward CMS


Measure Parts 1









DRAFT

PREVIEW



Additional Notes


DRAFT

PREVIEW


M1-306: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)* Measure Description:

Percentage of children and adolescents 1–17 years of age with a new prescription for an antipsychotic,

but no indication for antipsychotics, who had documentation of psychosocial care as first-line

treatment.


NQF Number 2801



Measure Parts 0


Numerator Description Children and adolescents from the denominator who had psychosocial care as first-line treatment prior to (or immediately following) a new prescription of an antipsychotic.

Denominator Description Children and adolescents who had a new prescription of an antipsychotic medication for which they do not have a U.S Food and Drug Administration primary indication.


Exclusions Exclude children and adolescents with a diagnosis of a condition for which antipsychotic medications have a U.S. Food and Drug Administration indication and are thus clinically appropriate: schizophrenia, bipolar disorder, psychotic disorder, autism, tic disorders.




Additional Notes


DRAFT

PREVIEW



M1-316: Alcohol Screening and Follow-up for People with Serious Mental Illness Measure Description:

The percentage of patients 18 years and older with a serious mental illness, who were screened for

unhealthy alcohol use and received brief counseling or other follow-up care if identified as an unhealthy

alcohol user.


NQF Number 2599



Measure Parts 1


Numerator Description Patients 18 years and older who are screened for unhealthy alcohol use during the last 3 months of the year prior to the measurement year through the first 9 months of the measurement year and received two events of counseling if identified as an unhealthy alcohol user.

Denominator Description All patients 18 years of age or older as of December 31 of the measurement year with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year.


Exclusions Active diagnosis of alcohol abuse or dependence during the first nine months of the year prior to the measurement year (see Alcohol Disorders Value Set).




Additional Notes

DRAFT

PREVIEW



M1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Measure Description:

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a

systematic screening method at least once within the last 24 months AND who received brief counseling

if identified as an unhealthy alcohol user


NQF Number 2152



Measure Parts 1


Numerator Description Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user



Exclusions Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy, other medical reasons)





MACRA MIPS Measure; CCBHC Measure.

DRAFT

PREVIEW



M1-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure) Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)

with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode

was identified


NQF Number 0104



Measure Parts 1


Numerator Description Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Denominator Description All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)






Additional Notes

MACRA MIPS Measure; CCBHC Measure. DRAFT

PREVIEW



M1-339: SUB-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge Measure Description:

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and

older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time

of hospital discharge, and a second rate, a subset of the first, which includes only those patients who

received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3)

describes patients who are identified with alcohol or drug use disorder who receive or refuse at

discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive

or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at

Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications

for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not

included.

These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use

(SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol

and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use:

Assessing Status after Discharge [temporarily suspended]).


NQF Number 1664



Measure Parts 2


Numerator Description SUB-3: The number of patients who received or refused at discharge a prescription for medication for treatment of alcohol or drug use disorder OR received or refused a referral for addictions treatment. SUB-3a: The number of patients who received a prescription at discharge for medication for treatment of alcohol or drug use disorder OR a referral for addictions treatment.

Denominator Description The number of hospitalized inpatients 18 years of age and older identified with an alcohol or drug use disorder


Exclusions There are 11 exclusions to the denominator as follows: • Patients less than 18 years of age • Patient drinking at unhealthy levels who do not meet criteria for an alcohol use disorder • Patients who are cognitively impaired • Patients who expire • Patients discharged to another hospital • Patients who left against medical advice • Patients discharged to another healthcare facility

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• Patients discharged to home or another healthcare facility for hospice care • Patients who have a length of stay less than or equal to three days or greater than 120 days • Patients who do not reside in the United States • Patients receiving Comfort Measures Only documented

DSRIP Specified Setting Behavioral Health: Inpatient, Hospital



Additional Notes

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M1-340: Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period. Measure Description:

This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of

current opioid addiction who were counseled regarding psychosocial and pharmacologic treatment

options for opioid addiction within the 12 month reporting period.


NQF Number NA

Measure Steward APA/NCQA/PCPI

Link to Measure Citation https://www.qualitymeasures.ahrq.gov/summaries/summary/27958/

Measure Parts 1


Numerator Description Patients who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period

Denominator Description All patients aged 18 years and older with a diagnosis of current opioid addiction



DSRIP Specified Setting Behavioral Health Outpatient, Primary Care, Outpatient Specialty Care

Data Source TBD



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https://www.qualitymeasures.ahrq.gov/summaries/summary/27958/


M1-341: Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting perio Measure Description:

This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of

current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment

options for alcohol dependence within the 12 month reporting period.


NQF Number NA

Measure Steward APA/NCQA/PCPI


Measure Parts 1


Numerator Description Patients who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period

Denominator Description All patients aged 18 years and older with a diagnosis of current alcohol dependence



DSRIP Specified Setting Behavioral Health Outpatient, Primary Care, Outpatient Specialty Care

Data Source TBD



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M1-342: Time to Initial Evaluation Measure Description:

Metric #1: The percentage of new consumers with initial evaluation provided within 10 business days of

first contact

Metric #2: The mean number of days until initial evaluation for new consumers


NQF Number NA

Measure Steward SAMHSA/CCBHC

Link to Measure Citation https://www.samhsa.gov/section-223/quality-measures

Measure Parts 1


Numerator Description The number of consumers in the eligible population who received an initial evaluation within 10 business days of the first contact with the provider entity during the measurement year.

Denominator Description The number of consumers in the eligible population. Report two age stratifications and a total rate: • 12–17 years as of the end of the measurement year • 18 years and older as of the end of the measurement year • Total (both age groups) Follow the steps below to identify the eligible population: Step 1: Identify new consumers who contacted the provider entity seeking services during the measurement year. Step 2: Identify consumers from step 1 aged 12 years and older as of the end of the measurement year.




Data Source TBD


Additional Notes

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https://www.samhsa.gov/section-223/quality-measures


M1-385: Assessment of Funcitonal Status or QoL (Modified from NQF# 0260/2624) Measure Description:

Percent of eligible patients who completed a health-related quality of life assessment or functional

assessment using a standardized tool at least once during the measurement period.


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Number of eligible patients who completed a health-related quality of life assessment or functional assessment using a standardized tool at least once during the measurement period.

Denominator Description Number of eligible individuals receiving specialty care services during the measurement period




Data Source TBD


Additional Notes For IDD Services

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M1-386: Improvement in Functional Status or QoL (Modified from PQRS #435) Measure Description:

Percent of patients who had a follow up health-related quality of life or functional status assessed

during the measurement period whose score stayed the same or improved.


NQF Number NA

Measure Steward NA


Measure Parts 1


Numerator Description Patients whose score stayed the same or improved.

Denominator Description Patients who had a follow up health-related quality of life or functional status assessed during the measurement period




Data Source TBD


Additional Notes For IDD Services

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M1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates) Measure Description:



NQF Number NA

Measure Steward NA


Measure Parts 2







Data Source TBD


Additional Notes Reported as two rates

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DRAFT PREVIEW DSRIP Category C Measure Specifications · 2017-06-27 · Patients who received a...

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